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15 Things Dermatologists Think Hospitalists Need to Know
- Maintain a broader range of differential diagnoses before ruling in or out something more concrete.
- Attend dermatology lectures as part of primary care’s continuing medical education courses.
- Review a good basic dermatology atlas from time to time.
- Learn to correctly describe lesions to a dermatologist by phone.
- Don’t assume that groin rashes are all fungal.
- Don’t mistakenly associate a drug-related reaction with a medication given one to two days before the onset of a rash.
- Consider involving a dermatologist to help manage open skin lesions, particularly if you’re unsure of the cause.
- Prescribe an adequate quantity of topical corticosteroids for the duration of treatment.
- Beware of painful or blistering rashes, especially if they involve the mucosa of the mouth, eyes, or genitals.
- Watch out for zoster, widespread herpes, pemphigus, and pemphigoid.
- Pay attention to itching in the wrists, genital region, and web spaces of fingers and toes.
- Be mindful of the rapid onset of purpuric lesions on the skin.
- Avoid consults for improving rashes and seborrheic keratosis, as well as nonurgent outpatient issues, such as psoriasis, rosacea, or a history of skin cancer.
- Don’t prescribe combined betamethasone/clotrimazole, also known as Lotrisone, for chronic scaly hands, feet, or groin.
- Encourage patients to follow up with a dermatologist on an outpatient basis.
Dermatologic diseases tend to receive little attention at most U.S. medical schools—typically only several days of lectures or a few weeks of clinical exposure.
“Not surprisingly, many general practitioners may feel unprepared to address hospitalized patients with challenging dermatologic findings,” says R. Samuel Hopkins, MD, assistant professor of dermatology and assistant residency program director at Oregon Health & Science University in Portland.
Few studies have examined the quality of inpatient dermatologic care. One study, a retrospective chart review at a Midwestern university hospital, found that the primary ward team submitted an accurate dermatologic diagnosis in only 23.9% of cases. Meanwhile, consultation with a dermatologist led to a change or addition to treatment in 77% of patients (Dermatol Online J. 2010;16(2):12).
“Given that medical schools may not be able to dedicate more time to managing dermatologic conditions, the burden of education may fall on post-graduate programs and continuing medical education to fill this gap,” Dr. Hopkins says. To further complicate matters, “it is difficult in many hospitals to obtain a dermatology consult on an inpatient, reflecting the limited access hospitalists often have to dermatologists.”
The most frequently encountered dermatologic conditions in the hospital setting are drug eruptions and skin infections. Dermatitis is the most misdiagnosed condition by nondermatologists in hospitals, says Russell Vinik, MD, co-director of the hospitalist group at the University of Utah Health Care in Salt Lake City.
The majority of skin issues don’t require a dermatologist’s input, but some do. “Clearly, there’s also the rash that we just don’t know what it is,” Dr. Vinik says. When in doubt, it’s best to err on the safe side and call the specialist.
Here’s how to assess whether to manage a dermatologic case yourself, or how to involve a dermatologist for appropriate diagnosis and treatment. In general, Dr. Hopkins says, “Whether one can handle a case on their own or not is a case-by-case decision by the hospitalist based on their comfort with their diagnosis and management.”
Maintain a broader range of differential diagnoses before ruling in or out something more concrete.
“Very often, patients with skin diseases are given a specific diagnosis without consideration of mimickers,” says Daniela Kroshinsky, MD, MPH, assistant professor of dermatology at Harvard Medical School in Boston.
“Cellulitis is a great example. People will come in with hot, red skin and be diagnosed with and treated for cellulitis but really have stasis dermatitis, Lyme [disease], gout, et cetera,” says Dr. Kroshinsky, who also is director of pediatric dermatology and director of inpatient dermatology, education, and research at Massachusetts General Hospital.
“The clinical picture of warm, red, tender skin can fit many conditions but is most often called cellulitis by nondermatologists,” she explains. “It’s not clear why, but I would suspect this is because cellulitis is one of the few dermatologic conditions taught in medical school, while the mimickers get less attention.”
Attend dermatology lectures as part of primary care’s continuing medical education courses.
This would increase your knowledge of skin conditions affecting hospitalized patients, Dr. Kroshinsky says. If there is a dermatologic consultant for your hospital, work closely with this specialist until you feel comfortable making diagnoses and incorporating treatment plans.
Similarly, if you are a resident who is interested in a career in hospital medicine, consider doing a rotation in dermatology.
Review a good basic dermatology atlas from time to time.
This keeps your mind open to differential diagnoses for a given situation that you may encounter in the hospital setting. A more comprehensive book or online reference can be helpful to peruse after seeing a patient with a particular rash, Dr. Kroshinsky says.
Learn to correctly describe lesions to a dermatologist by phone.
When a specialist isn’t available on site, the phone communication is vital to the specialist. This includes familiarizing yourself with some of the more life-threatening dermatologic problems, such as drug-induced hypersensitivity reactions. It will be easier to recognize when an urgent dermatologic consultation is required. Sometimes this is necessary when a patient doesn’t respond to treatment for a reasonable and presumed diagnosis—when one condition seems to mimic the symptoms of another, says Lindy Fox, MD, associate professor of clinical dermatology at the University of California at San Francisco and director of its hospital dermatology consultation service.
Don’t assume that groin rashes are all fungal.
In fact, there is a very large differential diagnosis for intertriginous eruptions, Dr. Fox says. Perform a KOH test (potassium hydroxide) and fungal cultures on intertriginous eruptions. If no fungus is identified or the patient is not responding appropriately to therapy, call for a dermatologic consultation.
Don’t mistakenly associate a drug-related reaction with a medication given one to two days before the onset of a rash.
It is typically seven to 10 days post-exposure that a drug eruption develops, Dr. Fox says. He suggests making a drug chart to highlight dates of medication administration. This helps pinpoint the most likely culprit based on timing and the probability that a certain drug may induce cutaneous eruptions. Correct identification of the type of drug eruption (e.g. simple drug eruption vs. hypersensitivity vs. potentially deadly Stevens-Johnson syndrome) is important.
Consider involving a dermatologist to help manage open skin lesions, particularly if you’re unsure of the cause.
There are many different causes of skin ulcers. Trauma, infections, and even malignancies can present as open wounds. Leg ulcers may be due to venous stasis, but they also can be caused by arterial insufficiency, vasculitis, and other conditions. A dermatologist might opt to perform a skin biopsy to help diagnose the lesion.
“Wound-care nurses can be very helpful in managing skin lesions, but they do not always have the experience needed to correctly diagnose the underlying problem,” says Kathryn Schwarzenberger, MD, professor of medicine at the University of Vermont College of Medicine in Burlington. “If you’re thinking of calling the wound-care nurse, think of calling the dermatologist first.”
Prescribe an adequate quantity of topical corticosteroids for the duration of treatment.
“It’s really important to provide enough medicine,” Dr. Schwarzenberger says. Typically, a patient will receive a small tube, apply the contents, and find that “it’s enough medicine to cover their body once. This doesn’t work if you intended to have the patient apply it all over for two weeks.”
It takes, on average, 30 g of a topical medication to cover the body once. With topical steroids, prescribing an insufficient quantity “dooms your therapy to failure.”
Allergic reactions from these medications are rare, and some insurance companies charge the same regardless of the size. Prescribing a small amount initially might incur an additional expense for the patient.
Beware of painful or blistering rashes, especially if they involve the mucosa of the mouth, eyes, or genitals.
“These symptoms can be associated with potentially deadly toxic epidermal necrolysis,” says Daniel Aires, MD, JD, director of the division of dermatology at the University of Kansas School of Medicine in Kansas City, Kan. “Consult dermatology immediately. The sooner treatment is begun, the better the odds of survival.”
If a rash involves the eye, call an ophthalmologist and a dermatologist. “Eyes are more likely than skin to develop chronic complications after resolution of an acute condition,” he says.
For a rash involving primarily the mouth, call an otolaryngologist, a dentist, or both, as well as a dermatologist. These specialists are more skilled in visualizing and treating oral conditions.
Watch out for zoster, widespread herpes, pemphigus, and pemphigoid.
These blistering conditions require urgent diagnosis and treatment, so a dermatologist’s expertise is needed quickly, Dr. Aires says. Even without the presence of blisters, a single region of the skin or “dermatome” gives pause for concern.
“This could be a sign of zoster, which is especially dangerous in immunosuppressed or otherwise debilitated patients,” he cautions. “Either perform a culture and begin treatment, or consult dermatology, or do both.”
Pay attention to itching in the wrists, genital region, and web spaces of fingers and toes.
This may be due to scabies infestation. “Scabies can spread rapidly throughout a hospital ward,” Dr. Aires says. What to do: Scrape for scabies, consider a trial of topical treatment, and consult a dermatologist if you’re unsure.
Be mindful of the rapid onset of purpuric lesionscon the skin.
They warrant suspicion of such conditions as vasculitis, hypercoaguable states, and disseminated angiotropic infections, says Dr. Hopkins of Oregon Health & Science University. “The shape and size of purpuric skin lesions help determine the etiology. A few characteristic examples include papular purpura and retiform purpura. Papular purpura [raised purpuric papules] may suggest vasculitis. Purpura that forms net-like patches is called retiform purpura and suggests a vaso-occlusive process, such as from a hypercoaguable state, embolic phenomena, or calciphylaxis.”
13 Avoid consults for improving rashes and seborrheic keratosis, as well as nonurgent outpatient issues, such as psoriasis, rosacea, or a history of skin cancer. These conditions “are more easily addressed in a clinic, as opposed to in a hospital, where the patient is lying in a bed feeling ill with IV tubes in place,” Dr. Aires says. “It also reflects respect for the dermatologist’s time. Inpatient dermatology can be pretty busy, so it’s preferable to consult primarily for urgent skin issues.” Consultations can be costly, too, and most patients would rather avoid additional medical bills.
Don’t prescribe combined betamethasone/clotrimazole, also known as Lotrisone, for chronic scaly hands, feet, or groin.
Although it is not harmful, “it is not usually a great choice for typical ‘dermatophyte’ fungal infections, such as athlete’s foot and ‘jock itch,’” Dr. Aires says. “Over-the-counter Lamisil is better, particularly following daily use of 10-minute soaks in 50-50 vinegar-water. Even for yeast infections, miconazole is better than clotrimazole.”
As for betamethasone, this “component is way too strong for the groin area and can cause atrophy or worse,” he says.
—Daniela Kroshinsky, MD, MPH, director of inpatient dermatology, education, and research, Massachusetts General Hospital, Boston
Encourage patients to follow up with a dermatologist on an outpatient basis.
By heeding this advice, patients are less likely to return to the ED for skin conditions that can be managed in an office, says Kirsten Flynn, MD, a dermatologist at Banner Health Center in Sun City West, Ariz. Inpatient admissions by dermatologists have been decreasing over the years. Most patients with skin diseases or cutaneous manifestations of systemic illnesses are admitted to hospitals by other physicians.
“Many dermatologists are happy to fit in urgent consults in their clinics. Drug eruptions are by far the most common consultation request,” says Dr. Flynn, who notes that high-dose IV steroids can cause complications, such as gastrointestinal bleeding, bowel perforation, opportunistic infections, and exacerbation of underlying diseases. “In most cases, removing the offending agent and providing supportive care is the best option.”
Susan Kreimer is a freelance writer in New York.
- Maintain a broader range of differential diagnoses before ruling in or out something more concrete.
- Attend dermatology lectures as part of primary care’s continuing medical education courses.
- Review a good basic dermatology atlas from time to time.
- Learn to correctly describe lesions to a dermatologist by phone.
- Don’t assume that groin rashes are all fungal.
- Don’t mistakenly associate a drug-related reaction with a medication given one to two days before the onset of a rash.
- Consider involving a dermatologist to help manage open skin lesions, particularly if you’re unsure of the cause.
- Prescribe an adequate quantity of topical corticosteroids for the duration of treatment.
- Beware of painful or blistering rashes, especially if they involve the mucosa of the mouth, eyes, or genitals.
- Watch out for zoster, widespread herpes, pemphigus, and pemphigoid.
- Pay attention to itching in the wrists, genital region, and web spaces of fingers and toes.
- Be mindful of the rapid onset of purpuric lesions on the skin.
- Avoid consults for improving rashes and seborrheic keratosis, as well as nonurgent outpatient issues, such as psoriasis, rosacea, or a history of skin cancer.
- Don’t prescribe combined betamethasone/clotrimazole, also known as Lotrisone, for chronic scaly hands, feet, or groin.
- Encourage patients to follow up with a dermatologist on an outpatient basis.
Dermatologic diseases tend to receive little attention at most U.S. medical schools—typically only several days of lectures or a few weeks of clinical exposure.
“Not surprisingly, many general practitioners may feel unprepared to address hospitalized patients with challenging dermatologic findings,” says R. Samuel Hopkins, MD, assistant professor of dermatology and assistant residency program director at Oregon Health & Science University in Portland.
Few studies have examined the quality of inpatient dermatologic care. One study, a retrospective chart review at a Midwestern university hospital, found that the primary ward team submitted an accurate dermatologic diagnosis in only 23.9% of cases. Meanwhile, consultation with a dermatologist led to a change or addition to treatment in 77% of patients (Dermatol Online J. 2010;16(2):12).
“Given that medical schools may not be able to dedicate more time to managing dermatologic conditions, the burden of education may fall on post-graduate programs and continuing medical education to fill this gap,” Dr. Hopkins says. To further complicate matters, “it is difficult in many hospitals to obtain a dermatology consult on an inpatient, reflecting the limited access hospitalists often have to dermatologists.”
The most frequently encountered dermatologic conditions in the hospital setting are drug eruptions and skin infections. Dermatitis is the most misdiagnosed condition by nondermatologists in hospitals, says Russell Vinik, MD, co-director of the hospitalist group at the University of Utah Health Care in Salt Lake City.
The majority of skin issues don’t require a dermatologist’s input, but some do. “Clearly, there’s also the rash that we just don’t know what it is,” Dr. Vinik says. When in doubt, it’s best to err on the safe side and call the specialist.
Here’s how to assess whether to manage a dermatologic case yourself, or how to involve a dermatologist for appropriate diagnosis and treatment. In general, Dr. Hopkins says, “Whether one can handle a case on their own or not is a case-by-case decision by the hospitalist based on their comfort with their diagnosis and management.”
Maintain a broader range of differential diagnoses before ruling in or out something more concrete.
“Very often, patients with skin diseases are given a specific diagnosis without consideration of mimickers,” says Daniela Kroshinsky, MD, MPH, assistant professor of dermatology at Harvard Medical School in Boston.
“Cellulitis is a great example. People will come in with hot, red skin and be diagnosed with and treated for cellulitis but really have stasis dermatitis, Lyme [disease], gout, et cetera,” says Dr. Kroshinsky, who also is director of pediatric dermatology and director of inpatient dermatology, education, and research at Massachusetts General Hospital.
“The clinical picture of warm, red, tender skin can fit many conditions but is most often called cellulitis by nondermatologists,” she explains. “It’s not clear why, but I would suspect this is because cellulitis is one of the few dermatologic conditions taught in medical school, while the mimickers get less attention.”
Attend dermatology lectures as part of primary care’s continuing medical education courses.
This would increase your knowledge of skin conditions affecting hospitalized patients, Dr. Kroshinsky says. If there is a dermatologic consultant for your hospital, work closely with this specialist until you feel comfortable making diagnoses and incorporating treatment plans.
Similarly, if you are a resident who is interested in a career in hospital medicine, consider doing a rotation in dermatology.
Review a good basic dermatology atlas from time to time.
This keeps your mind open to differential diagnoses for a given situation that you may encounter in the hospital setting. A more comprehensive book or online reference can be helpful to peruse after seeing a patient with a particular rash, Dr. Kroshinsky says.
Learn to correctly describe lesions to a dermatologist by phone.
When a specialist isn’t available on site, the phone communication is vital to the specialist. This includes familiarizing yourself with some of the more life-threatening dermatologic problems, such as drug-induced hypersensitivity reactions. It will be easier to recognize when an urgent dermatologic consultation is required. Sometimes this is necessary when a patient doesn’t respond to treatment for a reasonable and presumed diagnosis—when one condition seems to mimic the symptoms of another, says Lindy Fox, MD, associate professor of clinical dermatology at the University of California at San Francisco and director of its hospital dermatology consultation service.
Don’t assume that groin rashes are all fungal.
In fact, there is a very large differential diagnosis for intertriginous eruptions, Dr. Fox says. Perform a KOH test (potassium hydroxide) and fungal cultures on intertriginous eruptions. If no fungus is identified or the patient is not responding appropriately to therapy, call for a dermatologic consultation.
Don’t mistakenly associate a drug-related reaction with a medication given one to two days before the onset of a rash.
It is typically seven to 10 days post-exposure that a drug eruption develops, Dr. Fox says. He suggests making a drug chart to highlight dates of medication administration. This helps pinpoint the most likely culprit based on timing and the probability that a certain drug may induce cutaneous eruptions. Correct identification of the type of drug eruption (e.g. simple drug eruption vs. hypersensitivity vs. potentially deadly Stevens-Johnson syndrome) is important.
Consider involving a dermatologist to help manage open skin lesions, particularly if you’re unsure of the cause.
There are many different causes of skin ulcers. Trauma, infections, and even malignancies can present as open wounds. Leg ulcers may be due to venous stasis, but they also can be caused by arterial insufficiency, vasculitis, and other conditions. A dermatologist might opt to perform a skin biopsy to help diagnose the lesion.
“Wound-care nurses can be very helpful in managing skin lesions, but they do not always have the experience needed to correctly diagnose the underlying problem,” says Kathryn Schwarzenberger, MD, professor of medicine at the University of Vermont College of Medicine in Burlington. “If you’re thinking of calling the wound-care nurse, think of calling the dermatologist first.”
Prescribe an adequate quantity of topical corticosteroids for the duration of treatment.
“It’s really important to provide enough medicine,” Dr. Schwarzenberger says. Typically, a patient will receive a small tube, apply the contents, and find that “it’s enough medicine to cover their body once. This doesn’t work if you intended to have the patient apply it all over for two weeks.”
It takes, on average, 30 g of a topical medication to cover the body once. With topical steroids, prescribing an insufficient quantity “dooms your therapy to failure.”
Allergic reactions from these medications are rare, and some insurance companies charge the same regardless of the size. Prescribing a small amount initially might incur an additional expense for the patient.
Beware of painful or blistering rashes, especially if they involve the mucosa of the mouth, eyes, or genitals.
“These symptoms can be associated with potentially deadly toxic epidermal necrolysis,” says Daniel Aires, MD, JD, director of the division of dermatology at the University of Kansas School of Medicine in Kansas City, Kan. “Consult dermatology immediately. The sooner treatment is begun, the better the odds of survival.”
If a rash involves the eye, call an ophthalmologist and a dermatologist. “Eyes are more likely than skin to develop chronic complications after resolution of an acute condition,” he says.
For a rash involving primarily the mouth, call an otolaryngologist, a dentist, or both, as well as a dermatologist. These specialists are more skilled in visualizing and treating oral conditions.
Watch out for zoster, widespread herpes, pemphigus, and pemphigoid.
These blistering conditions require urgent diagnosis and treatment, so a dermatologist’s expertise is needed quickly, Dr. Aires says. Even without the presence of blisters, a single region of the skin or “dermatome” gives pause for concern.
“This could be a sign of zoster, which is especially dangerous in immunosuppressed or otherwise debilitated patients,” he cautions. “Either perform a culture and begin treatment, or consult dermatology, or do both.”
Pay attention to itching in the wrists, genital region, and web spaces of fingers and toes.
This may be due to scabies infestation. “Scabies can spread rapidly throughout a hospital ward,” Dr. Aires says. What to do: Scrape for scabies, consider a trial of topical treatment, and consult a dermatologist if you’re unsure.
Be mindful of the rapid onset of purpuric lesionscon the skin.
They warrant suspicion of such conditions as vasculitis, hypercoaguable states, and disseminated angiotropic infections, says Dr. Hopkins of Oregon Health & Science University. “The shape and size of purpuric skin lesions help determine the etiology. A few characteristic examples include papular purpura and retiform purpura. Papular purpura [raised purpuric papules] may suggest vasculitis. Purpura that forms net-like patches is called retiform purpura and suggests a vaso-occlusive process, such as from a hypercoaguable state, embolic phenomena, or calciphylaxis.”
13 Avoid consults for improving rashes and seborrheic keratosis, as well as nonurgent outpatient issues, such as psoriasis, rosacea, or a history of skin cancer. These conditions “are more easily addressed in a clinic, as opposed to in a hospital, where the patient is lying in a bed feeling ill with IV tubes in place,” Dr. Aires says. “It also reflects respect for the dermatologist’s time. Inpatient dermatology can be pretty busy, so it’s preferable to consult primarily for urgent skin issues.” Consultations can be costly, too, and most patients would rather avoid additional medical bills.
Don’t prescribe combined betamethasone/clotrimazole, also known as Lotrisone, for chronic scaly hands, feet, or groin.
Although it is not harmful, “it is not usually a great choice for typical ‘dermatophyte’ fungal infections, such as athlete’s foot and ‘jock itch,’” Dr. Aires says. “Over-the-counter Lamisil is better, particularly following daily use of 10-minute soaks in 50-50 vinegar-water. Even for yeast infections, miconazole is better than clotrimazole.”
As for betamethasone, this “component is way too strong for the groin area and can cause atrophy or worse,” he says.
—Daniela Kroshinsky, MD, MPH, director of inpatient dermatology, education, and research, Massachusetts General Hospital, Boston
Encourage patients to follow up with a dermatologist on an outpatient basis.
By heeding this advice, patients are less likely to return to the ED for skin conditions that can be managed in an office, says Kirsten Flynn, MD, a dermatologist at Banner Health Center in Sun City West, Ariz. Inpatient admissions by dermatologists have been decreasing over the years. Most patients with skin diseases or cutaneous manifestations of systemic illnesses are admitted to hospitals by other physicians.
“Many dermatologists are happy to fit in urgent consults in their clinics. Drug eruptions are by far the most common consultation request,” says Dr. Flynn, who notes that high-dose IV steroids can cause complications, such as gastrointestinal bleeding, bowel perforation, opportunistic infections, and exacerbation of underlying diseases. “In most cases, removing the offending agent and providing supportive care is the best option.”
Susan Kreimer is a freelance writer in New York.
- Maintain a broader range of differential diagnoses before ruling in or out something more concrete.
- Attend dermatology lectures as part of primary care’s continuing medical education courses.
- Review a good basic dermatology atlas from time to time.
- Learn to correctly describe lesions to a dermatologist by phone.
- Don’t assume that groin rashes are all fungal.
- Don’t mistakenly associate a drug-related reaction with a medication given one to two days before the onset of a rash.
- Consider involving a dermatologist to help manage open skin lesions, particularly if you’re unsure of the cause.
- Prescribe an adequate quantity of topical corticosteroids for the duration of treatment.
- Beware of painful or blistering rashes, especially if they involve the mucosa of the mouth, eyes, or genitals.
- Watch out for zoster, widespread herpes, pemphigus, and pemphigoid.
- Pay attention to itching in the wrists, genital region, and web spaces of fingers and toes.
- Be mindful of the rapid onset of purpuric lesions on the skin.
- Avoid consults for improving rashes and seborrheic keratosis, as well as nonurgent outpatient issues, such as psoriasis, rosacea, or a history of skin cancer.
- Don’t prescribe combined betamethasone/clotrimazole, also known as Lotrisone, for chronic scaly hands, feet, or groin.
- Encourage patients to follow up with a dermatologist on an outpatient basis.
Dermatologic diseases tend to receive little attention at most U.S. medical schools—typically only several days of lectures or a few weeks of clinical exposure.
“Not surprisingly, many general practitioners may feel unprepared to address hospitalized patients with challenging dermatologic findings,” says R. Samuel Hopkins, MD, assistant professor of dermatology and assistant residency program director at Oregon Health & Science University in Portland.
Few studies have examined the quality of inpatient dermatologic care. One study, a retrospective chart review at a Midwestern university hospital, found that the primary ward team submitted an accurate dermatologic diagnosis in only 23.9% of cases. Meanwhile, consultation with a dermatologist led to a change or addition to treatment in 77% of patients (Dermatol Online J. 2010;16(2):12).
“Given that medical schools may not be able to dedicate more time to managing dermatologic conditions, the burden of education may fall on post-graduate programs and continuing medical education to fill this gap,” Dr. Hopkins says. To further complicate matters, “it is difficult in many hospitals to obtain a dermatology consult on an inpatient, reflecting the limited access hospitalists often have to dermatologists.”
The most frequently encountered dermatologic conditions in the hospital setting are drug eruptions and skin infections. Dermatitis is the most misdiagnosed condition by nondermatologists in hospitals, says Russell Vinik, MD, co-director of the hospitalist group at the University of Utah Health Care in Salt Lake City.
The majority of skin issues don’t require a dermatologist’s input, but some do. “Clearly, there’s also the rash that we just don’t know what it is,” Dr. Vinik says. When in doubt, it’s best to err on the safe side and call the specialist.
Here’s how to assess whether to manage a dermatologic case yourself, or how to involve a dermatologist for appropriate diagnosis and treatment. In general, Dr. Hopkins says, “Whether one can handle a case on their own or not is a case-by-case decision by the hospitalist based on their comfort with their diagnosis and management.”
Maintain a broader range of differential diagnoses before ruling in or out something more concrete.
“Very often, patients with skin diseases are given a specific diagnosis without consideration of mimickers,” says Daniela Kroshinsky, MD, MPH, assistant professor of dermatology at Harvard Medical School in Boston.
“Cellulitis is a great example. People will come in with hot, red skin and be diagnosed with and treated for cellulitis but really have stasis dermatitis, Lyme [disease], gout, et cetera,” says Dr. Kroshinsky, who also is director of pediatric dermatology and director of inpatient dermatology, education, and research at Massachusetts General Hospital.
“The clinical picture of warm, red, tender skin can fit many conditions but is most often called cellulitis by nondermatologists,” she explains. “It’s not clear why, but I would suspect this is because cellulitis is one of the few dermatologic conditions taught in medical school, while the mimickers get less attention.”
Attend dermatology lectures as part of primary care’s continuing medical education courses.
This would increase your knowledge of skin conditions affecting hospitalized patients, Dr. Kroshinsky says. If there is a dermatologic consultant for your hospital, work closely with this specialist until you feel comfortable making diagnoses and incorporating treatment plans.
Similarly, if you are a resident who is interested in a career in hospital medicine, consider doing a rotation in dermatology.
Review a good basic dermatology atlas from time to time.
This keeps your mind open to differential diagnoses for a given situation that you may encounter in the hospital setting. A more comprehensive book or online reference can be helpful to peruse after seeing a patient with a particular rash, Dr. Kroshinsky says.
Learn to correctly describe lesions to a dermatologist by phone.
When a specialist isn’t available on site, the phone communication is vital to the specialist. This includes familiarizing yourself with some of the more life-threatening dermatologic problems, such as drug-induced hypersensitivity reactions. It will be easier to recognize when an urgent dermatologic consultation is required. Sometimes this is necessary when a patient doesn’t respond to treatment for a reasonable and presumed diagnosis—when one condition seems to mimic the symptoms of another, says Lindy Fox, MD, associate professor of clinical dermatology at the University of California at San Francisco and director of its hospital dermatology consultation service.
Don’t assume that groin rashes are all fungal.
In fact, there is a very large differential diagnosis for intertriginous eruptions, Dr. Fox says. Perform a KOH test (potassium hydroxide) and fungal cultures on intertriginous eruptions. If no fungus is identified or the patient is not responding appropriately to therapy, call for a dermatologic consultation.
Don’t mistakenly associate a drug-related reaction with a medication given one to two days before the onset of a rash.
It is typically seven to 10 days post-exposure that a drug eruption develops, Dr. Fox says. He suggests making a drug chart to highlight dates of medication administration. This helps pinpoint the most likely culprit based on timing and the probability that a certain drug may induce cutaneous eruptions. Correct identification of the type of drug eruption (e.g. simple drug eruption vs. hypersensitivity vs. potentially deadly Stevens-Johnson syndrome) is important.
Consider involving a dermatologist to help manage open skin lesions, particularly if you’re unsure of the cause.
There are many different causes of skin ulcers. Trauma, infections, and even malignancies can present as open wounds. Leg ulcers may be due to venous stasis, but they also can be caused by arterial insufficiency, vasculitis, and other conditions. A dermatologist might opt to perform a skin biopsy to help diagnose the lesion.
“Wound-care nurses can be very helpful in managing skin lesions, but they do not always have the experience needed to correctly diagnose the underlying problem,” says Kathryn Schwarzenberger, MD, professor of medicine at the University of Vermont College of Medicine in Burlington. “If you’re thinking of calling the wound-care nurse, think of calling the dermatologist first.”
Prescribe an adequate quantity of topical corticosteroids for the duration of treatment.
“It’s really important to provide enough medicine,” Dr. Schwarzenberger says. Typically, a patient will receive a small tube, apply the contents, and find that “it’s enough medicine to cover their body once. This doesn’t work if you intended to have the patient apply it all over for two weeks.”
It takes, on average, 30 g of a topical medication to cover the body once. With topical steroids, prescribing an insufficient quantity “dooms your therapy to failure.”
Allergic reactions from these medications are rare, and some insurance companies charge the same regardless of the size. Prescribing a small amount initially might incur an additional expense for the patient.
Beware of painful or blistering rashes, especially if they involve the mucosa of the mouth, eyes, or genitals.
“These symptoms can be associated with potentially deadly toxic epidermal necrolysis,” says Daniel Aires, MD, JD, director of the division of dermatology at the University of Kansas School of Medicine in Kansas City, Kan. “Consult dermatology immediately. The sooner treatment is begun, the better the odds of survival.”
If a rash involves the eye, call an ophthalmologist and a dermatologist. “Eyes are more likely than skin to develop chronic complications after resolution of an acute condition,” he says.
For a rash involving primarily the mouth, call an otolaryngologist, a dentist, or both, as well as a dermatologist. These specialists are more skilled in visualizing and treating oral conditions.
Watch out for zoster, widespread herpes, pemphigus, and pemphigoid.
These blistering conditions require urgent diagnosis and treatment, so a dermatologist’s expertise is needed quickly, Dr. Aires says. Even without the presence of blisters, a single region of the skin or “dermatome” gives pause for concern.
“This could be a sign of zoster, which is especially dangerous in immunosuppressed or otherwise debilitated patients,” he cautions. “Either perform a culture and begin treatment, or consult dermatology, or do both.”
Pay attention to itching in the wrists, genital region, and web spaces of fingers and toes.
This may be due to scabies infestation. “Scabies can spread rapidly throughout a hospital ward,” Dr. Aires says. What to do: Scrape for scabies, consider a trial of topical treatment, and consult a dermatologist if you’re unsure.
Be mindful of the rapid onset of purpuric lesionscon the skin.
They warrant suspicion of such conditions as vasculitis, hypercoaguable states, and disseminated angiotropic infections, says Dr. Hopkins of Oregon Health & Science University. “The shape and size of purpuric skin lesions help determine the etiology. A few characteristic examples include papular purpura and retiform purpura. Papular purpura [raised purpuric papules] may suggest vasculitis. Purpura that forms net-like patches is called retiform purpura and suggests a vaso-occlusive process, such as from a hypercoaguable state, embolic phenomena, or calciphylaxis.”
13 Avoid consults for improving rashes and seborrheic keratosis, as well as nonurgent outpatient issues, such as psoriasis, rosacea, or a history of skin cancer. These conditions “are more easily addressed in a clinic, as opposed to in a hospital, where the patient is lying in a bed feeling ill with IV tubes in place,” Dr. Aires says. “It also reflects respect for the dermatologist’s time. Inpatient dermatology can be pretty busy, so it’s preferable to consult primarily for urgent skin issues.” Consultations can be costly, too, and most patients would rather avoid additional medical bills.
Don’t prescribe combined betamethasone/clotrimazole, also known as Lotrisone, for chronic scaly hands, feet, or groin.
Although it is not harmful, “it is not usually a great choice for typical ‘dermatophyte’ fungal infections, such as athlete’s foot and ‘jock itch,’” Dr. Aires says. “Over-the-counter Lamisil is better, particularly following daily use of 10-minute soaks in 50-50 vinegar-water. Even for yeast infections, miconazole is better than clotrimazole.”
As for betamethasone, this “component is way too strong for the groin area and can cause atrophy or worse,” he says.
—Daniela Kroshinsky, MD, MPH, director of inpatient dermatology, education, and research, Massachusetts General Hospital, Boston
Encourage patients to follow up with a dermatologist on an outpatient basis.
By heeding this advice, patients are less likely to return to the ED for skin conditions that can be managed in an office, says Kirsten Flynn, MD, a dermatologist at Banner Health Center in Sun City West, Ariz. Inpatient admissions by dermatologists have been decreasing over the years. Most patients with skin diseases or cutaneous manifestations of systemic illnesses are admitted to hospitals by other physicians.
“Many dermatologists are happy to fit in urgent consults in their clinics. Drug eruptions are by far the most common consultation request,” says Dr. Flynn, who notes that high-dose IV steroids can cause complications, such as gastrointestinal bleeding, bowel perforation, opportunistic infections, and exacerbation of underlying diseases. “In most cases, removing the offending agent and providing supportive care is the best option.”
Susan Kreimer is a freelance writer in New York.
CORRECTION
A quote in the March 2013 story “Lucky No. 7?” did not accurately represent comments expressed by Bradley Eshbaugh, MBA, FACMPE, chief administrator of Hospitalists of Northern Michigan (HNM) in Traverse City, Mich. His quote should have read: “I really believe that [seven-on/seven-off] scheduling is probably more desirable to Generation Y, which tends to have a lot more life quality and life balance as part of their mentality.”
A quote in the March 2013 story “Lucky No. 7?” did not accurately represent comments expressed by Bradley Eshbaugh, MBA, FACMPE, chief administrator of Hospitalists of Northern Michigan (HNM) in Traverse City, Mich. His quote should have read: “I really believe that [seven-on/seven-off] scheduling is probably more desirable to Generation Y, which tends to have a lot more life quality and life balance as part of their mentality.”
A quote in the March 2013 story “Lucky No. 7?” did not accurately represent comments expressed by Bradley Eshbaugh, MBA, FACMPE, chief administrator of Hospitalists of Northern Michigan (HNM) in Traverse City, Mich. His quote should have read: “I really believe that [seven-on/seven-off] scheduling is probably more desirable to Generation Y, which tends to have a lot more life quality and life balance as part of their mentality.”
Thirty-Day Hospital Readmissions Drop in 2012, CMS Reports
Rate of 30-day, all-cause hospital readmissions for the fourth quarter of 2012, per the Centers for Medicare & Medicaid Services (CMS). The figure had fluctuated between 18.5% and 19.5% the prior five years. The drop corresponds with the implementation of Medicare penalties for higher-than-expected readmission rates. Previous studies of readmissions, including the recent Dartmouth Atlas of Health Care report described in last month’s “Innovations” found little or no progress on reducing hospital readmissions.
Larry Beresford is a freelance writer in Oakland, Calif.
References
- Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
- Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
- Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
- JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
- Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.
Rate of 30-day, all-cause hospital readmissions for the fourth quarter of 2012, per the Centers for Medicare & Medicaid Services (CMS). The figure had fluctuated between 18.5% and 19.5% the prior five years. The drop corresponds with the implementation of Medicare penalties for higher-than-expected readmission rates. Previous studies of readmissions, including the recent Dartmouth Atlas of Health Care report described in last month’s “Innovations” found little or no progress on reducing hospital readmissions.
Larry Beresford is a freelance writer in Oakland, Calif.
References
- Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
- Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
- Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
- JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
- Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.
Rate of 30-day, all-cause hospital readmissions for the fourth quarter of 2012, per the Centers for Medicare & Medicaid Services (CMS). The figure had fluctuated between 18.5% and 19.5% the prior five years. The drop corresponds with the implementation of Medicare penalties for higher-than-expected readmission rates. Previous studies of readmissions, including the recent Dartmouth Atlas of Health Care report described in last month’s “Innovations” found little or no progress on reducing hospital readmissions.
Larry Beresford is a freelance writer in Oakland, Calif.
References
- Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
- Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
- Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
- JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
- Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.
Rival Hospitalists Can Bring Havoc, or Healthy Competition to Hospitals
In November 2011, the board of directors of Lee Memorial Health System in Fort Myers, Fla., voted to close access at its four hospitals to any hospitalist who didn’t already practice there or wasn’t affiliated with private practices that contracted with the health system. According to a report in a local newspaper, the proliferation of competing hospitalist practices at Lee Memorial was contributing to high rates of patient and referring physician dissatisfaction and hospitalist turnover.1 As a result, the board limited new hospitalists from entering practice in their facilities until they could develop “rules of engagement” for the existing hospitalists through new contracts and standards of practice.
The Lee Memorial example of multiple, competing hospitalist groups—and individuals practicing hospital medicine, also known as “lone wolf” hospitalists—causing havoc is atypical of the fledgling medical specialty, which has seen rapid growth the past two decades. Even so, veteran hospitalists confirm that nowadays, with nearly 40,000 hospitalists practicing in a majority of U.S. hospitals, it’s not uncommon to have multiple groups or individuals working under the same hospital roof. What is concerning to some in the specialty is how the competition can turn ugly, especially considering SHM espouses such virtues as teamwork, leadership, and quality improvement (QI).
Even so, situations arise when multiple HM groups under one roof don’t get along. Sometimes those groups or individual practitioners compete, head to head, for new admissions. Some hospitals have patient populations carved out by capitated medical groups or staff/group model HMOs. Some specialty groups, cardiology or orthopedics, for example, choose to contract hospitalist groups for their patients, setting up potential conflicts with new admissions. Other hospitals have “lone wolf” hospitalists, basically a practice of one.
No matter the dynamic, hospital administrators are frustrated with their inability to control competitive situations, especially when competing groups or individuals do not act in conjunction with their strategic goals.
Depending on hospital bylaws and state regulations, it might be difficult to exclude hospitalists from practicing in the hospital or to cut off competition. Some hospitals even welcome competition—as a prime virtue in its own right, a way to advance quality, or to guard against staffing shortages. The challenge, hospitalists and administrators say, is to encourage multiple groups to work amicably alongside each other, cooperating on the hospital’s larger mission and working toward its quality targets—and to make sure clinicians focus less on competition and more on patients (see “The Magic Bullet: Communication,”).
—Lowell Palmer, MD, FHM, hospitalist, Southwest Washington Medical Center, Vancouver
Purposeful, Team-Based Medicine
Scott Nygaard, MD, Lee Memorial’s chief medical officer for physician services, announced on Aug. 29, 2012, that the health system was contracting with a newly formed medical group called Inpatient Specialists of Southwest Florida (ISSF), a partnership between Cape Coral, Fla.-based Hospitalist Group of Southwest Florida (HGSF) and national management company Cogent HMG based in Brentwood, Tenn. HGSF and Cogent HMG already had established practices in two of Lee’s four hospitals.
Other existing hospitalist groups are permitted to continue practicing in these hospitals, although only a contracted group will be able to recruit or add new physicians, Dr. Nygaard says.
“The bylaws did not allow us to formally close access for staff already in practice,” he said. Physicians have the option of joining ISSF, and eventually, he says, the other groups dwindled in numbers through attrition. As Lee Memorial’s sole provider of hospitalist care, ISSF’s long-term goal is to put HM on a similar footing with other hospital-based specialties, such as emergency medicine and anesthesiology.
As of late 2012, six hospitalist groups and more than 80 hospitalists practice at Lee Memorial hospitals; 40 of those hospitalists belong to ISSF. “The other groups were all offered an opportunity to discuss a contractual relationship with the system, but they declined,” Dr. Nygaard says.
The remaining groups had worked amicably alongside each other but in an atmosphere Dr. Nygaard likens to a flea market, with each group practicing its own separate business and business model.
A standardized approach conducive to achieving the hospital’s quality and performance targets was lacking, however. As a result, Lee Memorial implemented an HM standard of care within the system. It helped somewhat, Dr. Nygaard says, but it didn’t fix all of the competition problems.
“We have learned that variation is the enemy of quality, especially in the highly complex environment of an acute-care hospital, trying to generate the kinds of measurable results we are now being asked to provide,” he explains. “We need to be more organized, structured, and purposeful in an era of team-based medicine. You need committed, aligned partnerships offering appropriate incentives.”
The ISSF contract contains such performance incentives.
“The joint venture formalizes an informal, long-standing, collaborative relationship” between the two participating HM groups, says Joseph Daley, MD, co-founder and director of quality services for Hospitalist Group of Southwest Florida. “We bring substantial, local expertise to the table, and have been quality partners with both Lee Memorial and Cogent HMG.”
And, as of April, Lee Memorial spokesperson Mary Briggs reported patient satisfaction scores for hospitalists are improving. “We believe the changes put in place were the right ones,” she emailed The Hospitalist.
—Scott Nygaard, MD, chief medical officer for physician services, Lee Memorial Health System, Fort Myers, Fla.
Supply and Demand
Every local hospital environment is different, with HM group arrangements shaped to a large degree by supply and demand for physicians, says Brian Hazen, MD, chief of hospital medicine at Inova Fairfax Hospital in Falls Church, Va., one of five hospitals in the Inova system. Inova Fairfax employs the hospitalists in Dr. Hazen’s group but is also home to other groups, including a neurohospitalist service and about a half dozen solo practitioners. Dr. Hazen’s group receives administrative support from the hospital and primarily is assigned patients through the ED. Some of the private hospitalists don’t want to take ED call, he says, instead preferring to get referrals of insured patients from primary-care-physician groups.
“Here in the D.C. area, we’re reasonably well staffed by hospitalists, but we’re not fighting over patients. In fact, if it weren’t for the private physicians, we’d have trouble meeting current staffing needs,” Dr. Hazen says. “I have also seen competition in other hospital settings, but I haven’t been in a situation where the doctors were fighting over patients.”
The “lone wolf” hospitalists at Inova Fairfax work very hard, Dr. Hazen adds. “A lot of them have private practices, see patients in the hospital, and also take call. If one of them has to leave town on short notice, we can help them out. On the flip side, if we’re busy in the emergency department, we’ll call on them,” he says.
The ED receives instruction on which hospitalist group admits which patient, but sometimes referral mistakes are made.
“If we accidently admit a patient who should have gone to one of the private people, who depend on these admissions for their income, I let them choose whether we should continue to see that patient or do a transfer,” Dr. Hazen says. “For the most part, we all try to be nice people.”
In the current health-care environment, hospital administrators might be reluctant to erect barriers to multiple hospitalist practices under one roof for fear of restraining trade, just as they don’t stand in the way of primary-care physicians who want to follow their own patients into the hospital. It might be easier to enact equally enforced requirements for the credentialing and privileging of all hospitalists who want to practice at the hospital, spelling out expectations in such areas as following protocols. (In 2011, SHM issued a position paper on hospitalist credentialing that addressed the appropriate time to institute a credentialing category with privileging criteria for hospitalists, and how to preserve maximum flexibility within this process.)2
Hospitals can limit who they contract with, who gets administrative support—and how much—using financial and quality performance to shape contracting decisions. In many communities, that could serve as an excluder of multiple groups in the same building, but in other locales, the payor mix might be attractive enough for physicians to survive on billing alone, says Leslie Flores, MPH, of Nelson Flores Hospital Medicine Consultants. If the hospital isn’t providing financial support, it will have less influence over how that group does things.
Dr. Hazen says his employed hospitalist group at Inova Fairfax is represented on more than 20 hospital committees and quality initiatives in the hospital, and has demonstrated its alignment with the hospital’s goals. Recently, in response to the administration’s concerns about throughput, his group initiated geographic, multidisciplinary rounding.
“I can do this because I have elite physicians, and because I protect them from unreasonable expectations,” he says. “Everyone needs to understand that the hospital needs to survive, so the hospital has a right to expect certain things from its hospitalists, such as performance on length of stay, throughput, other core measures, and promptly answering pages. Everyone should understand that those are the rules. Being fair, honest, and transparent about expectations is not an unreasonable expectation.”
Competition among hospitalists should be on a professional basis, experts emphasize, and cooperation is in everyone’s best interests. But Lowell Palmer, MD, FHM, a hospitalist at Southwest Washington Medical Center in Vancouver, Wash., thinks competition can be a healthy thing for hospitalist groups.
“It forces us to make sure the services we provide are meeting the customer’s expectations,” says Dr. Palmer, who works with Cogent Physician Services, one of the three HM groups at Southwest Washington. “We can and do learn from each other.”
Impact of Health-Care Reform
Beware the transformation health-care reform is having on the dynamics of hospital-based practice and the competitive landscape facing more hospitalist groups, says Roger Heroux, MHA, PhD, CHE, consultant with Hospitalist Management Resources LLC. Reforms mean hospitalists are seeing an increased emphasis on coordinating with post-acute-care providers, improving care transitions, preventing readmissions, and meeting hospital targets for quality and patient safety.
Primary-care groups, accountable-care organizations (ACOs), and health plans could choose specific hospitalist practices they want to partner with to manage the care of their hospitalized members, but they will have clear performance expectations that those groups will need to meet, spelled out in benchmarks. Or, as some experts believe, they might opt to bring in their own hospitalist group.
“We’re spending our time working with existing hospitalist programs to help them be more efficient and effective, to manage risk, and to become aggressive about meeting the clinical benchmarks,” Heroux says. Hospitals, ACOs, and capitated groups can’t afford not to have a high-performing hospitalist program, so this will become a hallmark of survival for hospitalist programs as well. “In a highly managed environment, patients will be managed by a hospitalist group that is responsive to these expectations,” he says.
Larry Beresford is a freelance writer in Oakland, Calif.
References
- Gluck F. Lee Memorial Health Systems’ hospitalists under new controls. Fort Myers News Press. Dec. 1, 2011.
- Society of Hospital Medicine Position Statement on Hospitalist Credentialing and Medical Staff Privileges. SHM website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Where_We_Stand&Template=/CM/HTMLDisplay.cfm&ContentID=28262. Accessed April 1, 2013.
In November 2011, the board of directors of Lee Memorial Health System in Fort Myers, Fla., voted to close access at its four hospitals to any hospitalist who didn’t already practice there or wasn’t affiliated with private practices that contracted with the health system. According to a report in a local newspaper, the proliferation of competing hospitalist practices at Lee Memorial was contributing to high rates of patient and referring physician dissatisfaction and hospitalist turnover.1 As a result, the board limited new hospitalists from entering practice in their facilities until they could develop “rules of engagement” for the existing hospitalists through new contracts and standards of practice.
The Lee Memorial example of multiple, competing hospitalist groups—and individuals practicing hospital medicine, also known as “lone wolf” hospitalists—causing havoc is atypical of the fledgling medical specialty, which has seen rapid growth the past two decades. Even so, veteran hospitalists confirm that nowadays, with nearly 40,000 hospitalists practicing in a majority of U.S. hospitals, it’s not uncommon to have multiple groups or individuals working under the same hospital roof. What is concerning to some in the specialty is how the competition can turn ugly, especially considering SHM espouses such virtues as teamwork, leadership, and quality improvement (QI).
Even so, situations arise when multiple HM groups under one roof don’t get along. Sometimes those groups or individual practitioners compete, head to head, for new admissions. Some hospitals have patient populations carved out by capitated medical groups or staff/group model HMOs. Some specialty groups, cardiology or orthopedics, for example, choose to contract hospitalist groups for their patients, setting up potential conflicts with new admissions. Other hospitals have “lone wolf” hospitalists, basically a practice of one.
No matter the dynamic, hospital administrators are frustrated with their inability to control competitive situations, especially when competing groups or individuals do not act in conjunction with their strategic goals.
Depending on hospital bylaws and state regulations, it might be difficult to exclude hospitalists from practicing in the hospital or to cut off competition. Some hospitals even welcome competition—as a prime virtue in its own right, a way to advance quality, or to guard against staffing shortages. The challenge, hospitalists and administrators say, is to encourage multiple groups to work amicably alongside each other, cooperating on the hospital’s larger mission and working toward its quality targets—and to make sure clinicians focus less on competition and more on patients (see “The Magic Bullet: Communication,”).
—Lowell Palmer, MD, FHM, hospitalist, Southwest Washington Medical Center, Vancouver
Purposeful, Team-Based Medicine
Scott Nygaard, MD, Lee Memorial’s chief medical officer for physician services, announced on Aug. 29, 2012, that the health system was contracting with a newly formed medical group called Inpatient Specialists of Southwest Florida (ISSF), a partnership between Cape Coral, Fla.-based Hospitalist Group of Southwest Florida (HGSF) and national management company Cogent HMG based in Brentwood, Tenn. HGSF and Cogent HMG already had established practices in two of Lee’s four hospitals.
Other existing hospitalist groups are permitted to continue practicing in these hospitals, although only a contracted group will be able to recruit or add new physicians, Dr. Nygaard says.
“The bylaws did not allow us to formally close access for staff already in practice,” he said. Physicians have the option of joining ISSF, and eventually, he says, the other groups dwindled in numbers through attrition. As Lee Memorial’s sole provider of hospitalist care, ISSF’s long-term goal is to put HM on a similar footing with other hospital-based specialties, such as emergency medicine and anesthesiology.
As of late 2012, six hospitalist groups and more than 80 hospitalists practice at Lee Memorial hospitals; 40 of those hospitalists belong to ISSF. “The other groups were all offered an opportunity to discuss a contractual relationship with the system, but they declined,” Dr. Nygaard says.
The remaining groups had worked amicably alongside each other but in an atmosphere Dr. Nygaard likens to a flea market, with each group practicing its own separate business and business model.
A standardized approach conducive to achieving the hospital’s quality and performance targets was lacking, however. As a result, Lee Memorial implemented an HM standard of care within the system. It helped somewhat, Dr. Nygaard says, but it didn’t fix all of the competition problems.
“We have learned that variation is the enemy of quality, especially in the highly complex environment of an acute-care hospital, trying to generate the kinds of measurable results we are now being asked to provide,” he explains. “We need to be more organized, structured, and purposeful in an era of team-based medicine. You need committed, aligned partnerships offering appropriate incentives.”
The ISSF contract contains such performance incentives.
“The joint venture formalizes an informal, long-standing, collaborative relationship” between the two participating HM groups, says Joseph Daley, MD, co-founder and director of quality services for Hospitalist Group of Southwest Florida. “We bring substantial, local expertise to the table, and have been quality partners with both Lee Memorial and Cogent HMG.”
And, as of April, Lee Memorial spokesperson Mary Briggs reported patient satisfaction scores for hospitalists are improving. “We believe the changes put in place were the right ones,” she emailed The Hospitalist.
—Scott Nygaard, MD, chief medical officer for physician services, Lee Memorial Health System, Fort Myers, Fla.
Supply and Demand
Every local hospital environment is different, with HM group arrangements shaped to a large degree by supply and demand for physicians, says Brian Hazen, MD, chief of hospital medicine at Inova Fairfax Hospital in Falls Church, Va., one of five hospitals in the Inova system. Inova Fairfax employs the hospitalists in Dr. Hazen’s group but is also home to other groups, including a neurohospitalist service and about a half dozen solo practitioners. Dr. Hazen’s group receives administrative support from the hospital and primarily is assigned patients through the ED. Some of the private hospitalists don’t want to take ED call, he says, instead preferring to get referrals of insured patients from primary-care-physician groups.
“Here in the D.C. area, we’re reasonably well staffed by hospitalists, but we’re not fighting over patients. In fact, if it weren’t for the private physicians, we’d have trouble meeting current staffing needs,” Dr. Hazen says. “I have also seen competition in other hospital settings, but I haven’t been in a situation where the doctors were fighting over patients.”
The “lone wolf” hospitalists at Inova Fairfax work very hard, Dr. Hazen adds. “A lot of them have private practices, see patients in the hospital, and also take call. If one of them has to leave town on short notice, we can help them out. On the flip side, if we’re busy in the emergency department, we’ll call on them,” he says.
The ED receives instruction on which hospitalist group admits which patient, but sometimes referral mistakes are made.
“If we accidently admit a patient who should have gone to one of the private people, who depend on these admissions for their income, I let them choose whether we should continue to see that patient or do a transfer,” Dr. Hazen says. “For the most part, we all try to be nice people.”
In the current health-care environment, hospital administrators might be reluctant to erect barriers to multiple hospitalist practices under one roof for fear of restraining trade, just as they don’t stand in the way of primary-care physicians who want to follow their own patients into the hospital. It might be easier to enact equally enforced requirements for the credentialing and privileging of all hospitalists who want to practice at the hospital, spelling out expectations in such areas as following protocols. (In 2011, SHM issued a position paper on hospitalist credentialing that addressed the appropriate time to institute a credentialing category with privileging criteria for hospitalists, and how to preserve maximum flexibility within this process.)2
Hospitals can limit who they contract with, who gets administrative support—and how much—using financial and quality performance to shape contracting decisions. In many communities, that could serve as an excluder of multiple groups in the same building, but in other locales, the payor mix might be attractive enough for physicians to survive on billing alone, says Leslie Flores, MPH, of Nelson Flores Hospital Medicine Consultants. If the hospital isn’t providing financial support, it will have less influence over how that group does things.
Dr. Hazen says his employed hospitalist group at Inova Fairfax is represented on more than 20 hospital committees and quality initiatives in the hospital, and has demonstrated its alignment with the hospital’s goals. Recently, in response to the administration’s concerns about throughput, his group initiated geographic, multidisciplinary rounding.
“I can do this because I have elite physicians, and because I protect them from unreasonable expectations,” he says. “Everyone needs to understand that the hospital needs to survive, so the hospital has a right to expect certain things from its hospitalists, such as performance on length of stay, throughput, other core measures, and promptly answering pages. Everyone should understand that those are the rules. Being fair, honest, and transparent about expectations is not an unreasonable expectation.”
Competition among hospitalists should be on a professional basis, experts emphasize, and cooperation is in everyone’s best interests. But Lowell Palmer, MD, FHM, a hospitalist at Southwest Washington Medical Center in Vancouver, Wash., thinks competition can be a healthy thing for hospitalist groups.
“It forces us to make sure the services we provide are meeting the customer’s expectations,” says Dr. Palmer, who works with Cogent Physician Services, one of the three HM groups at Southwest Washington. “We can and do learn from each other.”
Impact of Health-Care Reform
Beware the transformation health-care reform is having on the dynamics of hospital-based practice and the competitive landscape facing more hospitalist groups, says Roger Heroux, MHA, PhD, CHE, consultant with Hospitalist Management Resources LLC. Reforms mean hospitalists are seeing an increased emphasis on coordinating with post-acute-care providers, improving care transitions, preventing readmissions, and meeting hospital targets for quality and patient safety.
Primary-care groups, accountable-care organizations (ACOs), and health plans could choose specific hospitalist practices they want to partner with to manage the care of their hospitalized members, but they will have clear performance expectations that those groups will need to meet, spelled out in benchmarks. Or, as some experts believe, they might opt to bring in their own hospitalist group.
“We’re spending our time working with existing hospitalist programs to help them be more efficient and effective, to manage risk, and to become aggressive about meeting the clinical benchmarks,” Heroux says. Hospitals, ACOs, and capitated groups can’t afford not to have a high-performing hospitalist program, so this will become a hallmark of survival for hospitalist programs as well. “In a highly managed environment, patients will be managed by a hospitalist group that is responsive to these expectations,” he says.
Larry Beresford is a freelance writer in Oakland, Calif.
References
- Gluck F. Lee Memorial Health Systems’ hospitalists under new controls. Fort Myers News Press. Dec. 1, 2011.
- Society of Hospital Medicine Position Statement on Hospitalist Credentialing and Medical Staff Privileges. SHM website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Where_We_Stand&Template=/CM/HTMLDisplay.cfm&ContentID=28262. Accessed April 1, 2013.
In November 2011, the board of directors of Lee Memorial Health System in Fort Myers, Fla., voted to close access at its four hospitals to any hospitalist who didn’t already practice there or wasn’t affiliated with private practices that contracted with the health system. According to a report in a local newspaper, the proliferation of competing hospitalist practices at Lee Memorial was contributing to high rates of patient and referring physician dissatisfaction and hospitalist turnover.1 As a result, the board limited new hospitalists from entering practice in their facilities until they could develop “rules of engagement” for the existing hospitalists through new contracts and standards of practice.
The Lee Memorial example of multiple, competing hospitalist groups—and individuals practicing hospital medicine, also known as “lone wolf” hospitalists—causing havoc is atypical of the fledgling medical specialty, which has seen rapid growth the past two decades. Even so, veteran hospitalists confirm that nowadays, with nearly 40,000 hospitalists practicing in a majority of U.S. hospitals, it’s not uncommon to have multiple groups or individuals working under the same hospital roof. What is concerning to some in the specialty is how the competition can turn ugly, especially considering SHM espouses such virtues as teamwork, leadership, and quality improvement (QI).
Even so, situations arise when multiple HM groups under one roof don’t get along. Sometimes those groups or individual practitioners compete, head to head, for new admissions. Some hospitals have patient populations carved out by capitated medical groups or staff/group model HMOs. Some specialty groups, cardiology or orthopedics, for example, choose to contract hospitalist groups for their patients, setting up potential conflicts with new admissions. Other hospitals have “lone wolf” hospitalists, basically a practice of one.
No matter the dynamic, hospital administrators are frustrated with their inability to control competitive situations, especially when competing groups or individuals do not act in conjunction with their strategic goals.
Depending on hospital bylaws and state regulations, it might be difficult to exclude hospitalists from practicing in the hospital or to cut off competition. Some hospitals even welcome competition—as a prime virtue in its own right, a way to advance quality, or to guard against staffing shortages. The challenge, hospitalists and administrators say, is to encourage multiple groups to work amicably alongside each other, cooperating on the hospital’s larger mission and working toward its quality targets—and to make sure clinicians focus less on competition and more on patients (see “The Magic Bullet: Communication,”).
—Lowell Palmer, MD, FHM, hospitalist, Southwest Washington Medical Center, Vancouver
Purposeful, Team-Based Medicine
Scott Nygaard, MD, Lee Memorial’s chief medical officer for physician services, announced on Aug. 29, 2012, that the health system was contracting with a newly formed medical group called Inpatient Specialists of Southwest Florida (ISSF), a partnership between Cape Coral, Fla.-based Hospitalist Group of Southwest Florida (HGSF) and national management company Cogent HMG based in Brentwood, Tenn. HGSF and Cogent HMG already had established practices in two of Lee’s four hospitals.
Other existing hospitalist groups are permitted to continue practicing in these hospitals, although only a contracted group will be able to recruit or add new physicians, Dr. Nygaard says.
“The bylaws did not allow us to formally close access for staff already in practice,” he said. Physicians have the option of joining ISSF, and eventually, he says, the other groups dwindled in numbers through attrition. As Lee Memorial’s sole provider of hospitalist care, ISSF’s long-term goal is to put HM on a similar footing with other hospital-based specialties, such as emergency medicine and anesthesiology.
As of late 2012, six hospitalist groups and more than 80 hospitalists practice at Lee Memorial hospitals; 40 of those hospitalists belong to ISSF. “The other groups were all offered an opportunity to discuss a contractual relationship with the system, but they declined,” Dr. Nygaard says.
The remaining groups had worked amicably alongside each other but in an atmosphere Dr. Nygaard likens to a flea market, with each group practicing its own separate business and business model.
A standardized approach conducive to achieving the hospital’s quality and performance targets was lacking, however. As a result, Lee Memorial implemented an HM standard of care within the system. It helped somewhat, Dr. Nygaard says, but it didn’t fix all of the competition problems.
“We have learned that variation is the enemy of quality, especially in the highly complex environment of an acute-care hospital, trying to generate the kinds of measurable results we are now being asked to provide,” he explains. “We need to be more organized, structured, and purposeful in an era of team-based medicine. You need committed, aligned partnerships offering appropriate incentives.”
The ISSF contract contains such performance incentives.
“The joint venture formalizes an informal, long-standing, collaborative relationship” between the two participating HM groups, says Joseph Daley, MD, co-founder and director of quality services for Hospitalist Group of Southwest Florida. “We bring substantial, local expertise to the table, and have been quality partners with both Lee Memorial and Cogent HMG.”
And, as of April, Lee Memorial spokesperson Mary Briggs reported patient satisfaction scores for hospitalists are improving. “We believe the changes put in place were the right ones,” she emailed The Hospitalist.
—Scott Nygaard, MD, chief medical officer for physician services, Lee Memorial Health System, Fort Myers, Fla.
Supply and Demand
Every local hospital environment is different, with HM group arrangements shaped to a large degree by supply and demand for physicians, says Brian Hazen, MD, chief of hospital medicine at Inova Fairfax Hospital in Falls Church, Va., one of five hospitals in the Inova system. Inova Fairfax employs the hospitalists in Dr. Hazen’s group but is also home to other groups, including a neurohospitalist service and about a half dozen solo practitioners. Dr. Hazen’s group receives administrative support from the hospital and primarily is assigned patients through the ED. Some of the private hospitalists don’t want to take ED call, he says, instead preferring to get referrals of insured patients from primary-care-physician groups.
“Here in the D.C. area, we’re reasonably well staffed by hospitalists, but we’re not fighting over patients. In fact, if it weren’t for the private physicians, we’d have trouble meeting current staffing needs,” Dr. Hazen says. “I have also seen competition in other hospital settings, but I haven’t been in a situation where the doctors were fighting over patients.”
The “lone wolf” hospitalists at Inova Fairfax work very hard, Dr. Hazen adds. “A lot of them have private practices, see patients in the hospital, and also take call. If one of them has to leave town on short notice, we can help them out. On the flip side, if we’re busy in the emergency department, we’ll call on them,” he says.
The ED receives instruction on which hospitalist group admits which patient, but sometimes referral mistakes are made.
“If we accidently admit a patient who should have gone to one of the private people, who depend on these admissions for their income, I let them choose whether we should continue to see that patient or do a transfer,” Dr. Hazen says. “For the most part, we all try to be nice people.”
In the current health-care environment, hospital administrators might be reluctant to erect barriers to multiple hospitalist practices under one roof for fear of restraining trade, just as they don’t stand in the way of primary-care physicians who want to follow their own patients into the hospital. It might be easier to enact equally enforced requirements for the credentialing and privileging of all hospitalists who want to practice at the hospital, spelling out expectations in such areas as following protocols. (In 2011, SHM issued a position paper on hospitalist credentialing that addressed the appropriate time to institute a credentialing category with privileging criteria for hospitalists, and how to preserve maximum flexibility within this process.)2
Hospitals can limit who they contract with, who gets administrative support—and how much—using financial and quality performance to shape contracting decisions. In many communities, that could serve as an excluder of multiple groups in the same building, but in other locales, the payor mix might be attractive enough for physicians to survive on billing alone, says Leslie Flores, MPH, of Nelson Flores Hospital Medicine Consultants. If the hospital isn’t providing financial support, it will have less influence over how that group does things.
Dr. Hazen says his employed hospitalist group at Inova Fairfax is represented on more than 20 hospital committees and quality initiatives in the hospital, and has demonstrated its alignment with the hospital’s goals. Recently, in response to the administration’s concerns about throughput, his group initiated geographic, multidisciplinary rounding.
“I can do this because I have elite physicians, and because I protect them from unreasonable expectations,” he says. “Everyone needs to understand that the hospital needs to survive, so the hospital has a right to expect certain things from its hospitalists, such as performance on length of stay, throughput, other core measures, and promptly answering pages. Everyone should understand that those are the rules. Being fair, honest, and transparent about expectations is not an unreasonable expectation.”
Competition among hospitalists should be on a professional basis, experts emphasize, and cooperation is in everyone’s best interests. But Lowell Palmer, MD, FHM, a hospitalist at Southwest Washington Medical Center in Vancouver, Wash., thinks competition can be a healthy thing for hospitalist groups.
“It forces us to make sure the services we provide are meeting the customer’s expectations,” says Dr. Palmer, who works with Cogent Physician Services, one of the three HM groups at Southwest Washington. “We can and do learn from each other.”
Impact of Health-Care Reform
Beware the transformation health-care reform is having on the dynamics of hospital-based practice and the competitive landscape facing more hospitalist groups, says Roger Heroux, MHA, PhD, CHE, consultant with Hospitalist Management Resources LLC. Reforms mean hospitalists are seeing an increased emphasis on coordinating with post-acute-care providers, improving care transitions, preventing readmissions, and meeting hospital targets for quality and patient safety.
Primary-care groups, accountable-care organizations (ACOs), and health plans could choose specific hospitalist practices they want to partner with to manage the care of their hospitalized members, but they will have clear performance expectations that those groups will need to meet, spelled out in benchmarks. Or, as some experts believe, they might opt to bring in their own hospitalist group.
“We’re spending our time working with existing hospitalist programs to help them be more efficient and effective, to manage risk, and to become aggressive about meeting the clinical benchmarks,” Heroux says. Hospitals, ACOs, and capitated groups can’t afford not to have a high-performing hospitalist program, so this will become a hallmark of survival for hospitalist programs as well. “In a highly managed environment, patients will be managed by a hospitalist group that is responsive to these expectations,” he says.
Larry Beresford is a freelance writer in Oakland, Calif.
References
- Gluck F. Lee Memorial Health Systems’ hospitalists under new controls. Fort Myers News Press. Dec. 1, 2011.
- Society of Hospital Medicine Position Statement on Hospitalist Credentialing and Medical Staff Privileges. SHM website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Where_We_Stand&Template=/CM/HTMLDisplay.cfm&ContentID=28262. Accessed April 1, 2013.
Bill Seeks to Enhance Patient Access to Post-Hospital Benefit
New national legislation proposed in March would change Medicare billing rules to allow patients to more easily access Medicare’s institutional skilled nursing care benefit following a hospital discharge. Currently, patients can get the benefit only after a qualifying three-day hospital stay. If they don’t qualify, they often have to pay out of pocket for the subsequent skilled nursing facility placement.
The Improving Access to Medicare Coverage Act, introduced by Reps. Joe Courtney (D-Conn.) and Tom Latham (R-Iowa) and Sen. Sherrod Brown (D-Ohio), would allow the time patients spend inside the hospital on “observation status” to count toward their required three-day hospital stay. It also would establish a 90-day appeal period for those who have been denied this benefit.
SHM is one of a dozen endorsing organizations, joining the American Medical Association, American Medical Directors Association, and AARP. For more information, check out this month’s “Policy Corner”.
Larry Beresford is a freelance writer in Oakland, Calif.
References
- Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
- Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
- Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
- JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
- Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.
New national legislation proposed in March would change Medicare billing rules to allow patients to more easily access Medicare’s institutional skilled nursing care benefit following a hospital discharge. Currently, patients can get the benefit only after a qualifying three-day hospital stay. If they don’t qualify, they often have to pay out of pocket for the subsequent skilled nursing facility placement.
The Improving Access to Medicare Coverage Act, introduced by Reps. Joe Courtney (D-Conn.) and Tom Latham (R-Iowa) and Sen. Sherrod Brown (D-Ohio), would allow the time patients spend inside the hospital on “observation status” to count toward their required three-day hospital stay. It also would establish a 90-day appeal period for those who have been denied this benefit.
SHM is one of a dozen endorsing organizations, joining the American Medical Association, American Medical Directors Association, and AARP. For more information, check out this month’s “Policy Corner”.
Larry Beresford is a freelance writer in Oakland, Calif.
References
- Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
- Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
- Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
- JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
- Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.
New national legislation proposed in March would change Medicare billing rules to allow patients to more easily access Medicare’s institutional skilled nursing care benefit following a hospital discharge. Currently, patients can get the benefit only after a qualifying three-day hospital stay. If they don’t qualify, they often have to pay out of pocket for the subsequent skilled nursing facility placement.
The Improving Access to Medicare Coverage Act, introduced by Reps. Joe Courtney (D-Conn.) and Tom Latham (R-Iowa) and Sen. Sherrod Brown (D-Ohio), would allow the time patients spend inside the hospital on “observation status” to count toward their required three-day hospital stay. It also would establish a 90-day appeal period for those who have been denied this benefit.
SHM is one of a dozen endorsing organizations, joining the American Medical Association, American Medical Directors Association, and AARP. For more information, check out this month’s “Policy Corner”.
Larry Beresford is a freelance writer in Oakland, Calif.
References
- Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
- Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
- Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
- JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
- Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.
Telehealth Technology Connects Specialists with First Responders in the Field
The VA Ann Arbor Healthcare System in Michigan is mobilizing telehealth technology for a disaster-relief initiative that aims to connect first responders in the field with medical specialists at the Ann Arbor Medical Center. As reported in Healthcare IT News, the Disaster Relief Telehealth System of Orion, Mich.-based JEMS Technology (www.jemstech.com) enables secure, live-streaming video to be sent to specialists, who can review the video and respond with medical advice.5
The Office of Emergency Management at the Ann Arbor VA supports emergency operations from four treatment sites serving 21 counties in Michigan and Ohio, as well as regional disaster preparedness.
In other technology news, the U.S. Army in March awarded a $2.5 million contract to brain-monitoring-device company NeuroWave Systems of Cleveland Heights, Ohio (www.neurowavesystems.com), to develop a wearable, miniaturized brain monitor to assess via electroencephalogram data for traumatic brain injury (TBI) in the field, directly at the point of suspected injury, such as on battlefronts. The device, called SeizTBI, is “small, lightweight, and designed for rapid deployment in austere environments,” explains NeuroWave principal investigator Stephan Bibian, MD. TBI accounted for 22% of U.S. troop casualties in the Iraq and Afghanistan conflicts, but fewer than half were identified in the field.
References
- Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
- Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
- Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
- JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
- Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.
The VA Ann Arbor Healthcare System in Michigan is mobilizing telehealth technology for a disaster-relief initiative that aims to connect first responders in the field with medical specialists at the Ann Arbor Medical Center. As reported in Healthcare IT News, the Disaster Relief Telehealth System of Orion, Mich.-based JEMS Technology (www.jemstech.com) enables secure, live-streaming video to be sent to specialists, who can review the video and respond with medical advice.5
The Office of Emergency Management at the Ann Arbor VA supports emergency operations from four treatment sites serving 21 counties in Michigan and Ohio, as well as regional disaster preparedness.
In other technology news, the U.S. Army in March awarded a $2.5 million contract to brain-monitoring-device company NeuroWave Systems of Cleveland Heights, Ohio (www.neurowavesystems.com), to develop a wearable, miniaturized brain monitor to assess via electroencephalogram data for traumatic brain injury (TBI) in the field, directly at the point of suspected injury, such as on battlefronts. The device, called SeizTBI, is “small, lightweight, and designed for rapid deployment in austere environments,” explains NeuroWave principal investigator Stephan Bibian, MD. TBI accounted for 22% of U.S. troop casualties in the Iraq and Afghanistan conflicts, but fewer than half were identified in the field.
References
- Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
- Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
- Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
- JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
- Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.
The VA Ann Arbor Healthcare System in Michigan is mobilizing telehealth technology for a disaster-relief initiative that aims to connect first responders in the field with medical specialists at the Ann Arbor Medical Center. As reported in Healthcare IT News, the Disaster Relief Telehealth System of Orion, Mich.-based JEMS Technology (www.jemstech.com) enables secure, live-streaming video to be sent to specialists, who can review the video and respond with medical advice.5
The Office of Emergency Management at the Ann Arbor VA supports emergency operations from four treatment sites serving 21 counties in Michigan and Ohio, as well as regional disaster preparedness.
In other technology news, the U.S. Army in March awarded a $2.5 million contract to brain-monitoring-device company NeuroWave Systems of Cleveland Heights, Ohio (www.neurowavesystems.com), to develop a wearable, miniaturized brain monitor to assess via electroencephalogram data for traumatic brain injury (TBI) in the field, directly at the point of suspected injury, such as on battlefronts. The device, called SeizTBI, is “small, lightweight, and designed for rapid deployment in austere environments,” explains NeuroWave principal investigator Stephan Bibian, MD. TBI accounted for 22% of U.S. troop casualties in the Iraq and Afghanistan conflicts, but fewer than half were identified in the field.
References
- Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
- Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
- Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
- JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
- Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.
AMA Report Offers Nine Steps to Help PCPs Prevent Readmissions
The American Medical Association recently released a report developed by a 21-member expert panel proposing a nine-step plan for primary-care-physician (PCP) practices to play an integral role in improving care transitions and preventing avoidable rehospitalizations.2 The report recommends focusing on more than just the hospital-admitting diagnosis, conducting a thorough patient health assessment, clarifying the patient’s short- and long-term goals, and coordinating care with other care settings.
With simultaneous research in JAMA concluding that the vast majority of readmissions are for reasons unrelated to the previous hospital stay, coordination between the inpatient and outpatient teams is crucial to successful transitions of care.3 Moreover, a recent survey showed that nearly 30% of PCPs say they miss alerts about patients’ test results from an electronic health record (EHR) notification system.4 According to the survey by Hardeep Singh, MD, MPH, and colleagues from the Michael E. DeBakey VA Medical Center in Houston, the doctors received on average 63 such alerts per day. Seventy percent reported that they cannot effectively manage the alerts, and more than half said that the current EHR notification system makes it possible to miss test results.
Larry Beresford is a freelance writer in Oakland, Calif.
References
- Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
- Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
- Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
- JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
- Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.
The American Medical Association recently released a report developed by a 21-member expert panel proposing a nine-step plan for primary-care-physician (PCP) practices to play an integral role in improving care transitions and preventing avoidable rehospitalizations.2 The report recommends focusing on more than just the hospital-admitting diagnosis, conducting a thorough patient health assessment, clarifying the patient’s short- and long-term goals, and coordinating care with other care settings.
With simultaneous research in JAMA concluding that the vast majority of readmissions are for reasons unrelated to the previous hospital stay, coordination between the inpatient and outpatient teams is crucial to successful transitions of care.3 Moreover, a recent survey showed that nearly 30% of PCPs say they miss alerts about patients’ test results from an electronic health record (EHR) notification system.4 According to the survey by Hardeep Singh, MD, MPH, and colleagues from the Michael E. DeBakey VA Medical Center in Houston, the doctors received on average 63 such alerts per day. Seventy percent reported that they cannot effectively manage the alerts, and more than half said that the current EHR notification system makes it possible to miss test results.
Larry Beresford is a freelance writer in Oakland, Calif.
References
- Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
- Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
- Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
- JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
- Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.
The American Medical Association recently released a report developed by a 21-member expert panel proposing a nine-step plan for primary-care-physician (PCP) practices to play an integral role in improving care transitions and preventing avoidable rehospitalizations.2 The report recommends focusing on more than just the hospital-admitting diagnosis, conducting a thorough patient health assessment, clarifying the patient’s short- and long-term goals, and coordinating care with other care settings.
With simultaneous research in JAMA concluding that the vast majority of readmissions are for reasons unrelated to the previous hospital stay, coordination between the inpatient and outpatient teams is crucial to successful transitions of care.3 Moreover, a recent survey showed that nearly 30% of PCPs say they miss alerts about patients’ test results from an electronic health record (EHR) notification system.4 According to the survey by Hardeep Singh, MD, MPH, and colleagues from the Michael E. DeBakey VA Medical Center in Houston, the doctors received on average 63 such alerts per day. Seventy percent reported that they cannot effectively manage the alerts, and more than half said that the current EHR notification system makes it possible to miss test results.
Larry Beresford is a freelance writer in Oakland, Calif.
References
- Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
- Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
- Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
- JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
- Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.
UCSF Engages Hospitalists to Improve Patient Communication
In a poster presented at HM12, Kathryn Quinn, MPH, CPPS, FACHE, described how her quality team at the University of California at San Francisco (UCSF) developed a checklist to improve physician communication with patients, then taught it to the attending hospitalist faculty.1 The project began with a list of 29 best practices for patient-physician interaction, as identified in medical literature. Hospitalists then voted for the elements they felt were most important to their practice, as well as those best able to be measured, and a top-10 list was created.
Quinn, the program manager for quality and safety in the division of hospital medicine at UCSF, says the communication best practices were “chosen by the people whose practices we are trying to change.”
The quality team presented the best practices in one-hour training sessions that included small-group role plays, explains co-investigator and UCSF hospitalist Diane Sliwka, MD. The training extended to outpatient physicians, medical specialists, and chief residents. Participants also were provided a laminated pocket card listing the interventions. They also received feedback from structured observations with patients on service.
Quinn says UCSF hospitalists have improved at knocking and asking permission to enter patient rooms, introducing themselves by name and role, and encouraging questions at the end of the interaction. They have been less successful at inquiring about the patient’s concerns early in the interview and at discussing duration of treatment and next steps.
“We learned that it takes more than just talk,” Quinn says. “Just telling physicians how to improve communication doesn’t mean it’s easy to do.”
Still to be determined is the project’s impact on patient satisfaction scores, although the hospitalists reported that they found the training and feedback helpful.
References
- Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
- Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
- Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
- JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
- Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.
In a poster presented at HM12, Kathryn Quinn, MPH, CPPS, FACHE, described how her quality team at the University of California at San Francisco (UCSF) developed a checklist to improve physician communication with patients, then taught it to the attending hospitalist faculty.1 The project began with a list of 29 best practices for patient-physician interaction, as identified in medical literature. Hospitalists then voted for the elements they felt were most important to their practice, as well as those best able to be measured, and a top-10 list was created.
Quinn, the program manager for quality and safety in the division of hospital medicine at UCSF, says the communication best practices were “chosen by the people whose practices we are trying to change.”
The quality team presented the best practices in one-hour training sessions that included small-group role plays, explains co-investigator and UCSF hospitalist Diane Sliwka, MD. The training extended to outpatient physicians, medical specialists, and chief residents. Participants also were provided a laminated pocket card listing the interventions. They also received feedback from structured observations with patients on service.
Quinn says UCSF hospitalists have improved at knocking and asking permission to enter patient rooms, introducing themselves by name and role, and encouraging questions at the end of the interaction. They have been less successful at inquiring about the patient’s concerns early in the interview and at discussing duration of treatment and next steps.
“We learned that it takes more than just talk,” Quinn says. “Just telling physicians how to improve communication doesn’t mean it’s easy to do.”
Still to be determined is the project’s impact on patient satisfaction scores, although the hospitalists reported that they found the training and feedback helpful.
References
- Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
- Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
- Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
- JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
- Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.
In a poster presented at HM12, Kathryn Quinn, MPH, CPPS, FACHE, described how her quality team at the University of California at San Francisco (UCSF) developed a checklist to improve physician communication with patients, then taught it to the attending hospitalist faculty.1 The project began with a list of 29 best practices for patient-physician interaction, as identified in medical literature. Hospitalists then voted for the elements they felt were most important to their practice, as well as those best able to be measured, and a top-10 list was created.
Quinn, the program manager for quality and safety in the division of hospital medicine at UCSF, says the communication best practices were “chosen by the people whose practices we are trying to change.”
The quality team presented the best practices in one-hour training sessions that included small-group role plays, explains co-investigator and UCSF hospitalist Diane Sliwka, MD. The training extended to outpatient physicians, medical specialists, and chief residents. Participants also were provided a laminated pocket card listing the interventions. They also received feedback from structured observations with patients on service.
Quinn says UCSF hospitalists have improved at knocking and asking permission to enter patient rooms, introducing themselves by name and role, and encouraging questions at the end of the interaction. They have been less successful at inquiring about the patient’s concerns early in the interview and at discussing duration of treatment and next steps.
“We learned that it takes more than just talk,” Quinn says. “Just telling physicians how to improve communication doesn’t mean it’s easy to do.”
Still to be determined is the project’s impact on patient satisfaction scores, although the hospitalists reported that they found the training and feedback helpful.
References
- Quinn K, Neeman N, Mourad M, Sliwka D. Communication coaching: A multifaceted intervention to improve physician-patient communication [abstract]. J Hosp Med. 2012;7 Suppl 2:S108.
- Sokol PE, Wynia MK. There and Home Again, Safely: Five Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association website. http://www.ama-assn.org/resources/doc/patient-safety/ambulatory-practices.pdf. Accessed February 12, 2013.
- Dharmarajan K, Hsieh AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013;309(4):355-363.
- JAMA Internal Medicine. Nearly one-third of physicians report missing electronic notification of test results. JAMA Internal Medicine website. Available at: http://media.jamanetwork.com/news-item/nearly-one-third-of-physicians-report-missing-electronic-notification-of-test-results/.Accessed April 8, 2013.
- Miliard M. VA enlists telehealth for disasters. Healthcare IT News website. http://www.healthcareitnews.com/news/va-enlists-telehealth-disasters. Published February 27, 2013. Accessed April 1, 2013.
Hospitalists Can Get Ahead Through Quality and Patient Safety Initiatives
Are you a hospitalist who, on daily rounds, often thinks, “There’s got to be a better way to do this”? You might be just the type of person who can carve a niche for yourself in hospital quality and patient safety—and advance your career in the process.
Successful navigation of the quality-improvement (QI) and patient-safety domains, according to three veteran hospitalists, requires an initial passion and an incremental approach. Now is an especially good time, they agree, for young hospitalists to engage in these types of initiatives.
Why Do It?
In her capacity as president of the Mid-Atlantic Business Unit for Brentwood, Tenn.-based CogentHMG, Julia Wright, MD, SFHM, FACP, often encourages young recruits to consider participation in QI and patient-safety initiatives. She admits that the transition from residency to a busy HM practice, with its higher patient volumes and a faster pace, can be daunting at first. Still, she tries to cultivate interest in initiatives and establish a realistic timeframe for involvement.
There are many reasons to consider this as a career step. Dr. Wright says that quality and patient safety dovetail with hospitalists’ initial reasons for choosing medicine: to improve patients’ lives.
Janet Nagamine, RN, MD, SFHM, former patient safety officer and assistant chief of quality at Kaiser Permanente in Santa Clara, Calif., describes the fit this way: “I might be a good doctor, but as a hospitalist, I rely on many others within the system to deliver, so my patients can’t get good care until the entire system is running well,” she says. “There are all kinds of opportunities to fix our [hospital] system, and I really believe that hospitalists cannot separate themselves from that engagement.”
Elizabeth Gundersen, MD, FHM, of Fort Lauderdale, Fla., agrees that it’s a natural step to think about the ways to make a difference on a larger level. At her former institution, the University of Massachusetts (UMass) Medical School in Worcester, she parlayed her interest in QI to work her way up from ground-level hospitalist to associate chief of her division and quality officer for the hospital. “Physicians get a lot of satisfaction from helping individual patients,” she says. “One thing I really liked about getting involved with quality improvement was being able to make a difference for patients on a systems level.”
An Incremental Path
The path to her current position began with a very specific issue for Dr. Nagamine, an SHM board member who also serves as a Project BOOST co-investigator. “Although I have been doing patient safety since before they had a name for it, I didn’t start out saying that I wanted a career in quality and safety,” she says. “I was trying to take better care of my patients with diabetes, but controlling their glucose was extremely challenging because all the related variables—timing and amount of their insulin dosage, when and how much they had eaten—were charted in different places. This made it hard to adjust their insulin appropriately.”
It quickly became clear to Dr. Nagamine that the solution had to be systemic. She realized that something as basic as taking care of her patients with diabetes required multiple departments (i.e. dietary, nursing, and pharmacy) to furnish information in an integrated manner. So she joined the diabetes committee and went to work on the issue. She helped devise a flow chart that could be used by all relevant departments. A further evolution on the path emanated from one of her patients receiving the wrong medication. She joined the medication safety committee, became chair, “and the next thing you know, I’m in charge of patient safety, and an assistant chief of quality.”
Training Is Necessary
QI and patient-safety methodologies have become sophisticated disciplines in the past two decades, Dr. Wright says. Access to training in QI basics now is readily available to early-career hospitalists. For example, CogentHMG offers program support for QI so that anyone interested “doesn’t have to start from scratch anymore; we can help show them the way and support them in doing it.”
This month, HM13 (www.hospital medicine2013.org)—just outside Washington, D.C.—will offer multiple sessions on quality, as well as the “Initiating Quality Improvement Projects with Built-In Sustainment” workshop, led by Center for Comprehensive Access and Delivery Research and Evaluation (CADRE) core investigator Peter Kaboli, MD, MS, who will address sustainability.
Beyond methodological tools, success in quality and patient safety requires the ability to motivate people, often across multiple disciplines, Dr. Nagamine says. “If you want things to work better, you must invite the right people to the table. For example, we often forget to include key nonclinical stakeholders,” she adds.
When working with hospitals across the country to implement rapid-response tTeams, Dr. Nagamine often reminds them to invite the operators, or “key people,” in the process.
“If you put patient safety at the core of your initiative and create the context for that, most people will agree that it’s the right thing to do and will get on board, even if it’s an extra step for them,” she says. “Know your audience, listen to their perspective, and learn what matters to them. And to most people, it matters that they give good patient care.”
Gretchen Henkel is a freelance writer in California.
Branch Out: QI and Patient-Safety Initiatives
Pick a passion. It’s best to choose an issue that’s important to you. “It has to be a
passion because much of the time it’s an uphill battle,” says Dr. Gundersen. She started with the issue of reducing readmissions, and with two colleagues pitched the idea of involving the UMass HM group in SHM’s Project BOOST. After that, she set out to become an expert on reducing readmissions, applying what she had learned to other successful initiatives.
Learn the lingo. Dr. Wright advises learning some of the most basic principles, such as Shewhart’s PDCA (Plan-Do-Check-Act) or Deming’s adaptation PDSA (Plan-Do-Study-Act) cycles; the quality tripod; and accessing resources made available from SHM. A member of SHM’s Hospital Quality and Patient Safety Committee, Dr. Wright says a subcommittee for leadership engagement has been created and furnishes tools and training for advancing quality initiatives. The Institute for Healthcare Improvement (www.ihi.org) also offers a wealth of measures, speaker series, and white papers on improvement in health care.
Start small. You can test your ability to work with interdisciplinary departments, often a prerequisite of many quality initiatives, by first joining a committee, Dr. Nagamine advises. “See how effective or persuasive you are in pitching an idea and seeing it through with other departments,” she says.
Brace for a marathon. “Most people,” Dr. Gundersen says, “do not hand you 100% of their cooperation and a budget you can work with.” It takes time to get buy-in, especially if you’re doing interdisciplinary initiatives. If possible, break your projects into achievable units. “Start with some quick wins. Small payoffs here and there can re-energize your team and eventually yield a larger payoff,” she says.
Limit sweat equity. It’s important to put in time at the start of a project to demonstrate your value, but if you’re constantly staying up late working on a project, consider pitching a compensated role to your boss. “Being a good citizen and volunteering for committees is one thing,” Dr. Nagamine cautions, “but taking on leadership roles in too many projects, without dedicated time, is not sustainable and can jeopardize the success of your projects.”
—Gretchen Henkel
Are you a hospitalist who, on daily rounds, often thinks, “There’s got to be a better way to do this”? You might be just the type of person who can carve a niche for yourself in hospital quality and patient safety—and advance your career in the process.
Successful navigation of the quality-improvement (QI) and patient-safety domains, according to three veteran hospitalists, requires an initial passion and an incremental approach. Now is an especially good time, they agree, for young hospitalists to engage in these types of initiatives.
Why Do It?
In her capacity as president of the Mid-Atlantic Business Unit for Brentwood, Tenn.-based CogentHMG, Julia Wright, MD, SFHM, FACP, often encourages young recruits to consider participation in QI and patient-safety initiatives. She admits that the transition from residency to a busy HM practice, with its higher patient volumes and a faster pace, can be daunting at first. Still, she tries to cultivate interest in initiatives and establish a realistic timeframe for involvement.
There are many reasons to consider this as a career step. Dr. Wright says that quality and patient safety dovetail with hospitalists’ initial reasons for choosing medicine: to improve patients’ lives.
Janet Nagamine, RN, MD, SFHM, former patient safety officer and assistant chief of quality at Kaiser Permanente in Santa Clara, Calif., describes the fit this way: “I might be a good doctor, but as a hospitalist, I rely on many others within the system to deliver, so my patients can’t get good care until the entire system is running well,” she says. “There are all kinds of opportunities to fix our [hospital] system, and I really believe that hospitalists cannot separate themselves from that engagement.”
Elizabeth Gundersen, MD, FHM, of Fort Lauderdale, Fla., agrees that it’s a natural step to think about the ways to make a difference on a larger level. At her former institution, the University of Massachusetts (UMass) Medical School in Worcester, she parlayed her interest in QI to work her way up from ground-level hospitalist to associate chief of her division and quality officer for the hospital. “Physicians get a lot of satisfaction from helping individual patients,” she says. “One thing I really liked about getting involved with quality improvement was being able to make a difference for patients on a systems level.”
An Incremental Path
The path to her current position began with a very specific issue for Dr. Nagamine, an SHM board member who also serves as a Project BOOST co-investigator. “Although I have been doing patient safety since before they had a name for it, I didn’t start out saying that I wanted a career in quality and safety,” she says. “I was trying to take better care of my patients with diabetes, but controlling their glucose was extremely challenging because all the related variables—timing and amount of their insulin dosage, when and how much they had eaten—were charted in different places. This made it hard to adjust their insulin appropriately.”
It quickly became clear to Dr. Nagamine that the solution had to be systemic. She realized that something as basic as taking care of her patients with diabetes required multiple departments (i.e. dietary, nursing, and pharmacy) to furnish information in an integrated manner. So she joined the diabetes committee and went to work on the issue. She helped devise a flow chart that could be used by all relevant departments. A further evolution on the path emanated from one of her patients receiving the wrong medication. She joined the medication safety committee, became chair, “and the next thing you know, I’m in charge of patient safety, and an assistant chief of quality.”
Training Is Necessary
QI and patient-safety methodologies have become sophisticated disciplines in the past two decades, Dr. Wright says. Access to training in QI basics now is readily available to early-career hospitalists. For example, CogentHMG offers program support for QI so that anyone interested “doesn’t have to start from scratch anymore; we can help show them the way and support them in doing it.”
This month, HM13 (www.hospital medicine2013.org)—just outside Washington, D.C.—will offer multiple sessions on quality, as well as the “Initiating Quality Improvement Projects with Built-In Sustainment” workshop, led by Center for Comprehensive Access and Delivery Research and Evaluation (CADRE) core investigator Peter Kaboli, MD, MS, who will address sustainability.
Beyond methodological tools, success in quality and patient safety requires the ability to motivate people, often across multiple disciplines, Dr. Nagamine says. “If you want things to work better, you must invite the right people to the table. For example, we often forget to include key nonclinical stakeholders,” she adds.
When working with hospitals across the country to implement rapid-response tTeams, Dr. Nagamine often reminds them to invite the operators, or “key people,” in the process.
“If you put patient safety at the core of your initiative and create the context for that, most people will agree that it’s the right thing to do and will get on board, even if it’s an extra step for them,” she says. “Know your audience, listen to their perspective, and learn what matters to them. And to most people, it matters that they give good patient care.”
Gretchen Henkel is a freelance writer in California.
Branch Out: QI and Patient-Safety Initiatives
Pick a passion. It’s best to choose an issue that’s important to you. “It has to be a
passion because much of the time it’s an uphill battle,” says Dr. Gundersen. She started with the issue of reducing readmissions, and with two colleagues pitched the idea of involving the UMass HM group in SHM’s Project BOOST. After that, she set out to become an expert on reducing readmissions, applying what she had learned to other successful initiatives.
Learn the lingo. Dr. Wright advises learning some of the most basic principles, such as Shewhart’s PDCA (Plan-Do-Check-Act) or Deming’s adaptation PDSA (Plan-Do-Study-Act) cycles; the quality tripod; and accessing resources made available from SHM. A member of SHM’s Hospital Quality and Patient Safety Committee, Dr. Wright says a subcommittee for leadership engagement has been created and furnishes tools and training for advancing quality initiatives. The Institute for Healthcare Improvement (www.ihi.org) also offers a wealth of measures, speaker series, and white papers on improvement in health care.
Start small. You can test your ability to work with interdisciplinary departments, often a prerequisite of many quality initiatives, by first joining a committee, Dr. Nagamine advises. “See how effective or persuasive you are in pitching an idea and seeing it through with other departments,” she says.
Brace for a marathon. “Most people,” Dr. Gundersen says, “do not hand you 100% of their cooperation and a budget you can work with.” It takes time to get buy-in, especially if you’re doing interdisciplinary initiatives. If possible, break your projects into achievable units. “Start with some quick wins. Small payoffs here and there can re-energize your team and eventually yield a larger payoff,” she says.
Limit sweat equity. It’s important to put in time at the start of a project to demonstrate your value, but if you’re constantly staying up late working on a project, consider pitching a compensated role to your boss. “Being a good citizen and volunteering for committees is one thing,” Dr. Nagamine cautions, “but taking on leadership roles in too many projects, without dedicated time, is not sustainable and can jeopardize the success of your projects.”
—Gretchen Henkel
Are you a hospitalist who, on daily rounds, often thinks, “There’s got to be a better way to do this”? You might be just the type of person who can carve a niche for yourself in hospital quality and patient safety—and advance your career in the process.
Successful navigation of the quality-improvement (QI) and patient-safety domains, according to three veteran hospitalists, requires an initial passion and an incremental approach. Now is an especially good time, they agree, for young hospitalists to engage in these types of initiatives.
Why Do It?
In her capacity as president of the Mid-Atlantic Business Unit for Brentwood, Tenn.-based CogentHMG, Julia Wright, MD, SFHM, FACP, often encourages young recruits to consider participation in QI and patient-safety initiatives. She admits that the transition from residency to a busy HM practice, with its higher patient volumes and a faster pace, can be daunting at first. Still, she tries to cultivate interest in initiatives and establish a realistic timeframe for involvement.
There are many reasons to consider this as a career step. Dr. Wright says that quality and patient safety dovetail with hospitalists’ initial reasons for choosing medicine: to improve patients’ lives.
Janet Nagamine, RN, MD, SFHM, former patient safety officer and assistant chief of quality at Kaiser Permanente in Santa Clara, Calif., describes the fit this way: “I might be a good doctor, but as a hospitalist, I rely on many others within the system to deliver, so my patients can’t get good care until the entire system is running well,” she says. “There are all kinds of opportunities to fix our [hospital] system, and I really believe that hospitalists cannot separate themselves from that engagement.”
Elizabeth Gundersen, MD, FHM, of Fort Lauderdale, Fla., agrees that it’s a natural step to think about the ways to make a difference on a larger level. At her former institution, the University of Massachusetts (UMass) Medical School in Worcester, she parlayed her interest in QI to work her way up from ground-level hospitalist to associate chief of her division and quality officer for the hospital. “Physicians get a lot of satisfaction from helping individual patients,” she says. “One thing I really liked about getting involved with quality improvement was being able to make a difference for patients on a systems level.”
An Incremental Path
The path to her current position began with a very specific issue for Dr. Nagamine, an SHM board member who also serves as a Project BOOST co-investigator. “Although I have been doing patient safety since before they had a name for it, I didn’t start out saying that I wanted a career in quality and safety,” she says. “I was trying to take better care of my patients with diabetes, but controlling their glucose was extremely challenging because all the related variables—timing and amount of their insulin dosage, when and how much they had eaten—were charted in different places. This made it hard to adjust their insulin appropriately.”
It quickly became clear to Dr. Nagamine that the solution had to be systemic. She realized that something as basic as taking care of her patients with diabetes required multiple departments (i.e. dietary, nursing, and pharmacy) to furnish information in an integrated manner. So she joined the diabetes committee and went to work on the issue. She helped devise a flow chart that could be used by all relevant departments. A further evolution on the path emanated from one of her patients receiving the wrong medication. She joined the medication safety committee, became chair, “and the next thing you know, I’m in charge of patient safety, and an assistant chief of quality.”
Training Is Necessary
QI and patient-safety methodologies have become sophisticated disciplines in the past two decades, Dr. Wright says. Access to training in QI basics now is readily available to early-career hospitalists. For example, CogentHMG offers program support for QI so that anyone interested “doesn’t have to start from scratch anymore; we can help show them the way and support them in doing it.”
This month, HM13 (www.hospital medicine2013.org)—just outside Washington, D.C.—will offer multiple sessions on quality, as well as the “Initiating Quality Improvement Projects with Built-In Sustainment” workshop, led by Center for Comprehensive Access and Delivery Research and Evaluation (CADRE) core investigator Peter Kaboli, MD, MS, who will address sustainability.
Beyond methodological tools, success in quality and patient safety requires the ability to motivate people, often across multiple disciplines, Dr. Nagamine says. “If you want things to work better, you must invite the right people to the table. For example, we often forget to include key nonclinical stakeholders,” she adds.
When working with hospitals across the country to implement rapid-response tTeams, Dr. Nagamine often reminds them to invite the operators, or “key people,” in the process.
“If you put patient safety at the core of your initiative and create the context for that, most people will agree that it’s the right thing to do and will get on board, even if it’s an extra step for them,” she says. “Know your audience, listen to their perspective, and learn what matters to them. And to most people, it matters that they give good patient care.”
Gretchen Henkel is a freelance writer in California.
Branch Out: QI and Patient-Safety Initiatives
Pick a passion. It’s best to choose an issue that’s important to you. “It has to be a
passion because much of the time it’s an uphill battle,” says Dr. Gundersen. She started with the issue of reducing readmissions, and with two colleagues pitched the idea of involving the UMass HM group in SHM’s Project BOOST. After that, she set out to become an expert on reducing readmissions, applying what she had learned to other successful initiatives.
Learn the lingo. Dr. Wright advises learning some of the most basic principles, such as Shewhart’s PDCA (Plan-Do-Check-Act) or Deming’s adaptation PDSA (Plan-Do-Study-Act) cycles; the quality tripod; and accessing resources made available from SHM. A member of SHM’s Hospital Quality and Patient Safety Committee, Dr. Wright says a subcommittee for leadership engagement has been created and furnishes tools and training for advancing quality initiatives. The Institute for Healthcare Improvement (www.ihi.org) also offers a wealth of measures, speaker series, and white papers on improvement in health care.
Start small. You can test your ability to work with interdisciplinary departments, often a prerequisite of many quality initiatives, by first joining a committee, Dr. Nagamine advises. “See how effective or persuasive you are in pitching an idea and seeing it through with other departments,” she says.
Brace for a marathon. “Most people,” Dr. Gundersen says, “do not hand you 100% of their cooperation and a budget you can work with.” It takes time to get buy-in, especially if you’re doing interdisciplinary initiatives. If possible, break your projects into achievable units. “Start with some quick wins. Small payoffs here and there can re-energize your team and eventually yield a larger payoff,” she says.
Limit sweat equity. It’s important to put in time at the start of a project to demonstrate your value, but if you’re constantly staying up late working on a project, consider pitching a compensated role to your boss. “Being a good citizen and volunteering for committees is one thing,” Dr. Nagamine cautions, “but taking on leadership roles in too many projects, without dedicated time, is not sustainable and can jeopardize the success of your projects.”
—Gretchen Henkel
Gluten-free diet may hold benefit in IBS
A gluten-free diet reduced stool frequency as well as small bowel permeability in irritable bowel syndrome patients without celiac disease.
The findings, published in the May issue of Gastroenterology, "support the need for further clinical intervention studies to evaluate the clinical effects of gluten withdrawal in patients with diarrhea-predominant IBS," reported Dr. Maria I. Vazquez-Roque and her colleagues.
Dr. Vasquez-Roque, of the Mayo Clinic’s Clinical Enteric Neuroscience Translational and Epidemiological Research Program, in Rochester, Minn., and her colleagues recruited 45 subjects (43 women) from a database of more than 800 patients with irritable bowel syndrome who had been evaluated at the Mayo Clinic.
All patients had diarrhea-predominant IBS (IBS-D), were not on a gluten-free diet prior to the study, and did not have celiac disease.
They were randomized to either a gluten-free diet or a gluten-containing diet for 28 days. Patients’ meals and snacks were ingested or prepared in the Mayo Clinical Research Unit, and study participants were asked to eat only the foods provided by the study dietitians during the entire study period, the authors wrote. Dietitians assessed diet compliance using direct questioning of participants.
After 28 days of the study, the investigators looked at several clinical and histologic markers.
First, they tallied stool frequency, and found that patients on the gluten-containing diet had more stools per day than gluten-free patients did (P = .04), with a 95% confidence interval for the absolute difference between number of stools per day at –0.652 to –0.015 (Gastroenterology 2013 Jan. 28 [doi: 10.1053/j.gastro.2013.01.049]).
"While the absolute difference in stool frequency is small, it is important to appreciate that this increased frequency is on a background of the typical increase in stool frequency (average 2.6 bowel movements/day at baseline) and consistency in patients with IBS-D," the authors wrote.
This effect was more pronounced in subjects who were HLA-DQ2 or 8 positive (95% CI, –1.005 to –0.092; P = .019), they added.
Next, the investigators looked at small bowel permeability.
They found increased small bowel permeability with gluten-containing diet patients relative to their gluten-free counterparts, based on both cumulative mannitol excretion levels and lactulose:mannitol ratio. Similarly, this effect was more pronounced in HLA-DQ2 or 8 positive patients.
"While the clinical significance of these changes in permeability is not demonstrated in the current study, the abundant experimental evidence from the published literature is that increased mucosal permeability enhances inflammation and leads to increased sensitivity," they wrote.
Finally, the authors looked at tight-junction mRNA expression.
"Alterations in intestinal permeability and jejunal mucosal tight junction (TJ) signaling have been described in IBS-D, including postinfectious IBS-D," they wrote.
They found that expressions of ZO-1, occludin, and claudin-1 mRNA in colonic mucosa were significantly lower with the gluten-containing diet, compared with the gluten-free patients, particularly in subjects with HLA-DQ2 or 8 positive status.
There were no significant variations in tight junction signaling in the small bowel mucosa.
The authors conceded several limitations to their study. For one, it "did not evaluate effects of gluten on the microbiome, afferent functions, or cytokine expression in the mucosal biopsies from patients before and after the interventions. These would be interesting parameters to include in future studies," they wrote.
Additionally, "our study does not specifically address the effects of gluten protein per se, and it is possible that other proteins in wheat flour may be responsible for the changes observed."
Nevertheless, "our data provide mechanistic explanations for the observation that gluten withdrawal may improve patient symptoms in IBS," they concluded.
The researchers disclosed receiving funding for this study from the National Institutes of Health. One investigator also disclosed having received grants from Alba Therapeutics, maker of the drug larazotide, used in celiac disease.
Recently, we have seen the emergence of
nonceliac gluten sensitivity as a distinct clinical entity. It is as if the medical
community has caught up to the food industry and the patients because there has
been an explosion in the availability of gluten-free foods and some patients,
without celiac disease, have been telling us they feel better when gluten has
been withdrawn from their diet.
A recent study from Australia demonstrated in a double-blind,
randomized study of a gluten-containing diet versus a gluten-free diet
that individuals with irritable bowel syndrome (IBS) who had self-selected as
being gluten sensitive experienced more gastrointestinal symptoms and fatigue
when exposed to the gluten-containing diet.
The investigators from the Mayo Clinic in Rochester,
Minn. extended these studies to patients with diarrhea-predominant
IBS who had not self-selected as being gluten sensitive. They demonstrated that
the gluten-free diet reduced stool frequency and small bowel permeability and
that the effect was most prominent in those who possessed the celiac disease at
risk genes, HLA DQ2 and DQ8.
Gluten is not fully digested by our digestive system,
unlike meat protein. The large amino acid molecules that remain after digestion
appear responsible for the development of celiac disease in some individuals
who are HLA DQ2 or -8 positive. It now appears that gluten (or other
proteins found in wheat) may induce changes that result in symptoms in patients
labeled as having IBS.
So those that have already self-diagnosed as being
gluten sensitive may in fact just be the tip of the iceberg of gluten
sensitivity.
Peter H.R. Green, M.D., is the Director of
the Celiac Disease Center, Columbia University, New York, and professor of
clinical medicine at the College of Physicians and Surgeons. Dr. Green is on
the scientific advisory boards for Alvine Pharmaceuticals and ImmusanT.
Recently, we have seen the emergence of
nonceliac gluten sensitivity as a distinct clinical entity. It is as if the medical
community has caught up to the food industry and the patients because there has
been an explosion in the availability of gluten-free foods and some patients,
without celiac disease, have been telling us they feel better when gluten has
been withdrawn from their diet.
A recent study from Australia demonstrated in a double-blind,
randomized study of a gluten-containing diet versus a gluten-free diet
that individuals with irritable bowel syndrome (IBS) who had self-selected as
being gluten sensitive experienced more gastrointestinal symptoms and fatigue
when exposed to the gluten-containing diet.
The investigators from the Mayo Clinic in Rochester,
Minn. extended these studies to patients with diarrhea-predominant
IBS who had not self-selected as being gluten sensitive. They demonstrated that
the gluten-free diet reduced stool frequency and small bowel permeability and
that the effect was most prominent in those who possessed the celiac disease at
risk genes, HLA DQ2 and DQ8.
Gluten is not fully digested by our digestive system,
unlike meat protein. The large amino acid molecules that remain after digestion
appear responsible for the development of celiac disease in some individuals
who are HLA DQ2 or -8 positive. It now appears that gluten (or other
proteins found in wheat) may induce changes that result in symptoms in patients
labeled as having IBS.
So those that have already self-diagnosed as being
gluten sensitive may in fact just be the tip of the iceberg of gluten
sensitivity.
Peter H.R. Green, M.D., is the Director of
the Celiac Disease Center, Columbia University, New York, and professor of
clinical medicine at the College of Physicians and Surgeons. Dr. Green is on
the scientific advisory boards for Alvine Pharmaceuticals and ImmusanT.
Recently, we have seen the emergence of
nonceliac gluten sensitivity as a distinct clinical entity. It is as if the medical
community has caught up to the food industry and the patients because there has
been an explosion in the availability of gluten-free foods and some patients,
without celiac disease, have been telling us they feel better when gluten has
been withdrawn from their diet.
A recent study from Australia demonstrated in a double-blind,
randomized study of a gluten-containing diet versus a gluten-free diet
that individuals with irritable bowel syndrome (IBS) who had self-selected as
being gluten sensitive experienced more gastrointestinal symptoms and fatigue
when exposed to the gluten-containing diet.
The investigators from the Mayo Clinic in Rochester,
Minn. extended these studies to patients with diarrhea-predominant
IBS who had not self-selected as being gluten sensitive. They demonstrated that
the gluten-free diet reduced stool frequency and small bowel permeability and
that the effect was most prominent in those who possessed the celiac disease at
risk genes, HLA DQ2 and DQ8.
Gluten is not fully digested by our digestive system,
unlike meat protein. The large amino acid molecules that remain after digestion
appear responsible for the development of celiac disease in some individuals
who are HLA DQ2 or -8 positive. It now appears that gluten (or other
proteins found in wheat) may induce changes that result in symptoms in patients
labeled as having IBS.
So those that have already self-diagnosed as being
gluten sensitive may in fact just be the tip of the iceberg of gluten
sensitivity.
Peter H.R. Green, M.D., is the Director of
the Celiac Disease Center, Columbia University, New York, and professor of
clinical medicine at the College of Physicians and Surgeons. Dr. Green is on
the scientific advisory boards for Alvine Pharmaceuticals and ImmusanT.
A gluten-free diet reduced stool frequency as well as small bowel permeability in irritable bowel syndrome patients without celiac disease.
The findings, published in the May issue of Gastroenterology, "support the need for further clinical intervention studies to evaluate the clinical effects of gluten withdrawal in patients with diarrhea-predominant IBS," reported Dr. Maria I. Vazquez-Roque and her colleagues.
Dr. Vasquez-Roque, of the Mayo Clinic’s Clinical Enteric Neuroscience Translational and Epidemiological Research Program, in Rochester, Minn., and her colleagues recruited 45 subjects (43 women) from a database of more than 800 patients with irritable bowel syndrome who had been evaluated at the Mayo Clinic.
All patients had diarrhea-predominant IBS (IBS-D), were not on a gluten-free diet prior to the study, and did not have celiac disease.
They were randomized to either a gluten-free diet or a gluten-containing diet for 28 days. Patients’ meals and snacks were ingested or prepared in the Mayo Clinical Research Unit, and study participants were asked to eat only the foods provided by the study dietitians during the entire study period, the authors wrote. Dietitians assessed diet compliance using direct questioning of participants.
After 28 days of the study, the investigators looked at several clinical and histologic markers.
First, they tallied stool frequency, and found that patients on the gluten-containing diet had more stools per day than gluten-free patients did (P = .04), with a 95% confidence interval for the absolute difference between number of stools per day at –0.652 to –0.015 (Gastroenterology 2013 Jan. 28 [doi: 10.1053/j.gastro.2013.01.049]).
"While the absolute difference in stool frequency is small, it is important to appreciate that this increased frequency is on a background of the typical increase in stool frequency (average 2.6 bowel movements/day at baseline) and consistency in patients with IBS-D," the authors wrote.
This effect was more pronounced in subjects who were HLA-DQ2 or 8 positive (95% CI, –1.005 to –0.092; P = .019), they added.
Next, the investigators looked at small bowel permeability.
They found increased small bowel permeability with gluten-containing diet patients relative to their gluten-free counterparts, based on both cumulative mannitol excretion levels and lactulose:mannitol ratio. Similarly, this effect was more pronounced in HLA-DQ2 or 8 positive patients.
"While the clinical significance of these changes in permeability is not demonstrated in the current study, the abundant experimental evidence from the published literature is that increased mucosal permeability enhances inflammation and leads to increased sensitivity," they wrote.
Finally, the authors looked at tight-junction mRNA expression.
"Alterations in intestinal permeability and jejunal mucosal tight junction (TJ) signaling have been described in IBS-D, including postinfectious IBS-D," they wrote.
They found that expressions of ZO-1, occludin, and claudin-1 mRNA in colonic mucosa were significantly lower with the gluten-containing diet, compared with the gluten-free patients, particularly in subjects with HLA-DQ2 or 8 positive status.
There were no significant variations in tight junction signaling in the small bowel mucosa.
The authors conceded several limitations to their study. For one, it "did not evaluate effects of gluten on the microbiome, afferent functions, or cytokine expression in the mucosal biopsies from patients before and after the interventions. These would be interesting parameters to include in future studies," they wrote.
Additionally, "our study does not specifically address the effects of gluten protein per se, and it is possible that other proteins in wheat flour may be responsible for the changes observed."
Nevertheless, "our data provide mechanistic explanations for the observation that gluten withdrawal may improve patient symptoms in IBS," they concluded.
The researchers disclosed receiving funding for this study from the National Institutes of Health. One investigator also disclosed having received grants from Alba Therapeutics, maker of the drug larazotide, used in celiac disease.
A gluten-free diet reduced stool frequency as well as small bowel permeability in irritable bowel syndrome patients without celiac disease.
The findings, published in the May issue of Gastroenterology, "support the need for further clinical intervention studies to evaluate the clinical effects of gluten withdrawal in patients with diarrhea-predominant IBS," reported Dr. Maria I. Vazquez-Roque and her colleagues.
Dr. Vasquez-Roque, of the Mayo Clinic’s Clinical Enteric Neuroscience Translational and Epidemiological Research Program, in Rochester, Minn., and her colleagues recruited 45 subjects (43 women) from a database of more than 800 patients with irritable bowel syndrome who had been evaluated at the Mayo Clinic.
All patients had diarrhea-predominant IBS (IBS-D), were not on a gluten-free diet prior to the study, and did not have celiac disease.
They were randomized to either a gluten-free diet or a gluten-containing diet for 28 days. Patients’ meals and snacks were ingested or prepared in the Mayo Clinical Research Unit, and study participants were asked to eat only the foods provided by the study dietitians during the entire study period, the authors wrote. Dietitians assessed diet compliance using direct questioning of participants.
After 28 days of the study, the investigators looked at several clinical and histologic markers.
First, they tallied stool frequency, and found that patients on the gluten-containing diet had more stools per day than gluten-free patients did (P = .04), with a 95% confidence interval for the absolute difference between number of stools per day at –0.652 to –0.015 (Gastroenterology 2013 Jan. 28 [doi: 10.1053/j.gastro.2013.01.049]).
"While the absolute difference in stool frequency is small, it is important to appreciate that this increased frequency is on a background of the typical increase in stool frequency (average 2.6 bowel movements/day at baseline) and consistency in patients with IBS-D," the authors wrote.
This effect was more pronounced in subjects who were HLA-DQ2 or 8 positive (95% CI, –1.005 to –0.092; P = .019), they added.
Next, the investigators looked at small bowel permeability.
They found increased small bowel permeability with gluten-containing diet patients relative to their gluten-free counterparts, based on both cumulative mannitol excretion levels and lactulose:mannitol ratio. Similarly, this effect was more pronounced in HLA-DQ2 or 8 positive patients.
"While the clinical significance of these changes in permeability is not demonstrated in the current study, the abundant experimental evidence from the published literature is that increased mucosal permeability enhances inflammation and leads to increased sensitivity," they wrote.
Finally, the authors looked at tight-junction mRNA expression.
"Alterations in intestinal permeability and jejunal mucosal tight junction (TJ) signaling have been described in IBS-D, including postinfectious IBS-D," they wrote.
They found that expressions of ZO-1, occludin, and claudin-1 mRNA in colonic mucosa were significantly lower with the gluten-containing diet, compared with the gluten-free patients, particularly in subjects with HLA-DQ2 or 8 positive status.
There were no significant variations in tight junction signaling in the small bowel mucosa.
The authors conceded several limitations to their study. For one, it "did not evaluate effects of gluten on the microbiome, afferent functions, or cytokine expression in the mucosal biopsies from patients before and after the interventions. These would be interesting parameters to include in future studies," they wrote.
Additionally, "our study does not specifically address the effects of gluten protein per se, and it is possible that other proteins in wheat flour may be responsible for the changes observed."
Nevertheless, "our data provide mechanistic explanations for the observation that gluten withdrawal may improve patient symptoms in IBS," they concluded.
The researchers disclosed receiving funding for this study from the National Institutes of Health. One investigator also disclosed having received grants from Alba Therapeutics, maker of the drug larazotide, used in celiac disease.
FROM GASTROENTEROLOGY
Major finding: Irritable bowel syndrome patients on a gluten-free diet had fewer bowel movements per day than did gluten-consuming counterparts (P = .04).
Data source: A 4-week trial of 45 patients with diarrhea-predominant irritable bowel syndrome, randomized to a gluten-free or gluten-containing diet.
Disclosures: The researchers disclosed receiving funding for this study from the National Institutes of Health. One investigator also disclosed having received grants from Alba Therapeutics, maker of the drug larazotide, used in celiac disease.