On Nov. 1, 2012, the Centers for Medicare & Medicaid Services (CMS) released the final regulation implementing increased Medicaid payments for specified primary-care services to 100% of Medicare levels in 2013 and 2014.

Covered Medicaid services include evaluation and management codes between 99201 and 99499 when used by physicians with a specialty designation of family medicine, general internal medicine, or pediatric medicine. CMS also finalized a policy to qualify services provided by subspecialists related to the designated primary-care specialists board-certified by the American Board of Medical Specialties, American Osteopathic Association, and the American Board of Physician Specialties. Advanced-practice clinicians also qualify for the increased payment when services are furnished under a physician’s personal supervision.

In commenting on the proposed rule, SHM stated that hospitalists should qualify for purposes of the increased payment because they are an important part of the “team” of clinicians required to treat many common conditions within the Medicaid population, and that hospitalists often provide the first contact and facilitate an entry point into the comprehensive care network.

CMS agreed.

The codes included in the pay increase will be limited to traditional primary care but also will include hospital observation and consultation for inpatient services provided by nonadmitting physicians, ED services, and critical-care services.

Hospitalists will qualify for the enhanced payment, but it remains somewhat unclear how individual states will handle the increase. State Medicaid agencies could pay physicians based on their self-attestation alone or in conjunction with any other provider enrollment requirements that currently exist in the state. Further, inclusion of a code does not require a state to pay for the service if it is not already covered under the state’s Medicaid program. All other state coverage and payment policy rules related to the services also remain in effect.

Timing of the pay increase also remains unclear. The statute requires that states make higher payments for services provided on or after Jan. 1, 2013, but for many physicians, the higher payment might be longer in coming despite being retroactive to the January deadline. States must submit a State Plan Amendment (SPA) to reflect the fee schedule rate increases by March 31, 2013, and CMS may then take up to 90 days to review and approve the SPA. Therefore, it could be six months or longer before eligible physicians and practitioners receive any of the payment increase.

States will receive an estimated $5.8 billion in 2013 and $6.1 billion in 2014 in federal funds to meet this two-year requirement, unless Congress acts to extend or fund the provision permanently. In response to an SHM suggestion on the potential to extend the increase, CMS will be collecting relevant data on the impact of the pay increase on Medicaid patients.

Even with the remaining uncertainty and timing issues, this is a change in payment policy that presents an important shift in the valuation of primary-care services, including some services provided by hospitalists. Medicaid services are notoriously undervalued, and this increase to providers will certainly have a positive impact on the accessibility of care for patients.

Josh Boswell is SHM’s interim senior manager of government relations.

On Nov. 1, 2012, the Centers for Medicare & Medicaid Services (CMS) released the final regulation implementing increased Medicaid payments for specified primary-care services to 100% of Medicare levels in 2013 and 2014.

Covered Medicaid services include evaluation and management codes between 99201 and 99499 when used by physicians with a specialty designation of family medicine, general internal medicine, or pediatric medicine. CMS also finalized a policy to qualify services provided by subspecialists related to the designated primary-care specialists board-certified by the American Board of Medical Specialties, American Osteopathic Association, and the American Board of Physician Specialties. Advanced-practice clinicians also qualify for the increased payment when services are furnished under a physician’s personal supervision.

In commenting on the proposed rule, SHM stated that hospitalists should qualify for purposes of the increased payment because they are an important part of the “team” of clinicians required to treat many common conditions within the Medicaid population, and that hospitalists often provide the first contact and facilitate an entry point into the comprehensive care network.

CMS agreed.

The codes included in the pay increase will be limited to traditional primary care but also will include hospital observation and consultation for inpatient services provided by nonadmitting physicians, ED services, and critical-care services.

Hospitalists will qualify for the enhanced payment, but it remains somewhat unclear how individual states will handle the increase. State Medicaid agencies could pay physicians based on their self-attestation alone or in conjunction with any other provider enrollment requirements that currently exist in the state. Further, inclusion of a code does not require a state to pay for the service if it is not already covered under the state’s Medicaid program. All other state coverage and payment policy rules related to the services also remain in effect.

Timing of the pay increase also remains unclear. The statute requires that states make higher payments for services provided on or after Jan. 1, 2013, but for many physicians, the higher payment might be longer in coming despite being retroactive to the January deadline. States must submit a State Plan Amendment (SPA) to reflect the fee schedule rate increases by March 31, 2013, and CMS may then take up to 90 days to review and approve the SPA. Therefore, it could be six months or longer before eligible physicians and practitioners receive any of the payment increase.

States will receive an estimated $5.8 billion in 2013 and $6.1 billion in 2014 in federal funds to meet this two-year requirement, unless Congress acts to extend or fund the provision permanently. In response to an SHM suggestion on the potential to extend the increase, CMS will be collecting relevant data on the impact of the pay increase on Medicaid patients.

Even with the remaining uncertainty and timing issues, this is a change in payment policy that presents an important shift in the valuation of primary-care services, including some services provided by hospitalists. Medicaid services are notoriously undervalued, and this increase to providers will certainly have a positive impact on the accessibility of care for patients.

Josh Boswell is SHM’s interim senior manager of government relations.

On Nov. 1, 2012, the Centers for Medicare & Medicaid Services (CMS) released the final regulation implementing increased Medicaid payments for specified primary-care services to 100% of Medicare levels in 2013 and 2014.

Covered Medicaid services include evaluation and management codes between 99201 and 99499 when used by physicians with a specialty designation of family medicine, general internal medicine, or pediatric medicine. CMS also finalized a policy to qualify services provided by subspecialists related to the designated primary-care specialists board-certified by the American Board of Medical Specialties, American Osteopathic Association, and the American Board of Physician Specialties. Advanced-practice clinicians also qualify for the increased payment when services are furnished under a physician’s personal supervision.

In commenting on the proposed rule, SHM stated that hospitalists should qualify for purposes of the increased payment because they are an important part of the “team” of clinicians required to treat many common conditions within the Medicaid population, and that hospitalists often provide the first contact and facilitate an entry point into the comprehensive care network.

CMS agreed.

The codes included in the pay increase will be limited to traditional primary care but also will include hospital observation and consultation for inpatient services provided by nonadmitting physicians, ED services, and critical-care services.

Hospitalists will qualify for the enhanced payment, but it remains somewhat unclear how individual states will handle the increase. State Medicaid agencies could pay physicians based on their self-attestation alone or in conjunction with any other provider enrollment requirements that currently exist in the state. Further, inclusion of a code does not require a state to pay for the service if it is not already covered under the state’s Medicaid program. All other state coverage and payment policy rules related to the services also remain in effect.

Timing of the pay increase also remains unclear. The statute requires that states make higher payments for services provided on or after Jan. 1, 2013, but for many physicians, the higher payment might be longer in coming despite being retroactive to the January deadline. States must submit a State Plan Amendment (SPA) to reflect the fee schedule rate increases by March 31, 2013, and CMS may then take up to 90 days to review and approve the SPA. Therefore, it could be six months or longer before eligible physicians and practitioners receive any of the payment increase.

States will receive an estimated $5.8 billion in 2013 and $6.1 billion in 2014 in federal funds to meet this two-year requirement, unless Congress acts to extend or fund the provision permanently. In response to an SHM suggestion on the potential to extend the increase, CMS will be collecting relevant data on the impact of the pay increase on Medicaid patients.

Even with the remaining uncertainty and timing issues, this is a change in payment policy that presents an important shift in the valuation of primary-care services, including some services provided by hospitalists. Medicaid services are notoriously undervalued, and this increase to providers will certainly have a positive impact on the accessibility of care for patients.

Josh Boswell is SHM’s interim senior manager of government relations.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Interventions that improve discharge handovers reviewed
2. Duration of in-hospital cardiac resuscitation and survival rates
3. Early sepsis intervention strategies to decrease mortality risk
4. Hypoglycemia linked to increased mortality in critically ill
5. Increased bleeding risk for cardiac patients
6. Hospital-run vs. anesthesiologist-run preoperative clinics
7. Postoperative delirium and cognitive impairment in cardiac patients
8. Benefits of resuming anticoagulants after GI bleeding
9. Preoperative hyponatremia and risk of perioperative mortality

Systematic Review Highlights Several Interventions That Improve Discharge Handovers

Clinical question: Do interventions to improve patient handovers at discharge have positive effects on patient care?

Background: The transition from hospital to primary care is often suboptimal and has been associated with unfavorable outcomes, including hospital readmission, increased healthcare utilization, and adverse drug events post-discharge. This review sought to characterize different types of interventions aimed at improving discharge handovers and to evaluate their effects.

Study design: Systematic review of randomized controlled trials.

Setting: Studies published from January 1990 to March 2011.

Synopsis: Review of published databases identified 36 randomized controlled studies on interventions to improve discharge handovers. Studies were blindly evaluated by two reviewers on quality, interventions, and outcomes. There was significant heterogeneity in interventions and outcomes; thus, statistical analysis was not possible. Most studies evaluated multicomponent interventions and had more than one outcome measure.

Of the 36 studies reviewed, 25 reported statistically significant improvements in outcomes, including reduced hospital utilization and improved continuity of care. Effective interventions included medication reconciliation; structured discharge information (facilitated by electronic resources); multidisciplinary discharge planning; shared involvement in arranging care between inpatient and outpatient physicians; and Web-based access to discharge information by the outpatient provider.

The complexity of the interventions and the heterogeneity of reported results did not allow for firm conclusions to be drawn regarding which specific interventions had the strongest effects.

Bottom line: Interventions that target the quality and safety of handovers between hospital and outpatient providers at discharge can significantly reduce hospital utilization and improve continuity of care.

Citation: Hesselink G, Schoonhoven L, Barach P, et al. Improving patient handovers from hospital to primary care: a systematic review. Ann Intern Med. 2012;157:417-428.

Longer Duration of In-Hospital Cardiac Resuscitation Associated with Increased Survival

Clinical question: Are prolonged cardiac resuscitation efforts associated with improved outcomes?

Background: There is little evidence or guidelines on how long to maintain resuscitative efforts during in-hospital cardiac arrest, leading to variation in practice. This study characterized patterns of resuscitation duration and relationship to the return of spontaneous circulation and survival to discharge.

Study design: Retrospective observational study.

Setting: Four hundred thirty-five U.S. hospitals reporting data to the American Heart Association’s Get With The Guidelines: Resuscitation registry.

Synopsis: Using duration of resuscitation in nonsurvivors as a surrogate for the tendency of a facility to perform prolonged efforts, hospitals were divided into quartiles. Overall, of 64,339 patients in the registry, 31,198 (48.5%) had return of circulation and 9,912 (15.4%) survived to discharge. Resuscitative efforts in nonsurvivors ranged from a median of 16 to 25 minutes between the lowest and highest quartiles.

There was a stepwise increase in the likelihood for patients to have return of spontaneous circulation and to survive to discharge between each quartile. Specifically, comparing shortest to longest, there was a significant adjusted odds ratio of 1.12 for both the return of circulation (P<0.0001) and survival to discharge (P=0.021). The survival benefit was most apparent for those with pulseless electrical activity or asystole as initial rhythms, as compared to ventricular tachycardia or fibrillation.

Limitations included the study’s observational design, which meant causality could not be determined. Additionally, the study did not account for the quality of resuscitative efforts (e.g. depth of chest compressions, adherence with guidelines), which might have influenced outcomes. Importantly, the study looked at survival to discharge, but it did not evaluate long-term survival or functional status post-discharge, which might better reflect the success of resuscitation.

Bottom line: Prolonged resuscitative efforts were observed to be associated with increased likelihood of return of spontaneous circulation and survival to discharge; this data might provide clinical guidance in determining when to stop resuscitation efforts.

Citation: Goldberger ZD, Chan PS, Berg RA, et al. Duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study. Lancet. 2012;380:1473-1481.

Early Sepsis Intervention Strategies Decrease Mortality, Length of Stay, and Cost

Clinical question: For patients with sepsis or septic shock, what is the impact of a real-time comprehensive continuous quality-improvement (QI) initiative on in-hospital mortality, morbidity, and healthcare resource utilization in community and tertiary-care hospitals in the U.S.?

Background: Multiple single-center trials have demonstrated that early sepsis intervention strategies (early goal-directed therapy, resuscitation bundles) improve in-hospital mortality. Little is known about the effectiveness of incorporating these strategies into a real-time continuous QI initiative and implementing interventions across multiple sites simultaneously.

Study design: Pre-post at some sites and concurrent implementation design at other sites.

Setting: Five community and six-tertiary care U.S. hospitals.

Synopsis: The GENeralized Early Sepsis Intervention Strategies (GENESIS) project was a CQI initiative that combined several QI concepts with validated early sepsis interventions known as resuscitation bundles (RB). Continuous QI was implemented on patients with severe sepsis or septic shock in both before and after designs (eight hospitals), and in concurrent designs (three hospitals). The control group was comprised of historical controls treated before GENESIS and patients with incomplete implementation of RB, totaling 1,554 patients. The treatment group included patients treated after GENESIS and those with complete RB compliance, totaling 4,801 patients.

Compared with the control group, patients in the treatment group had a 33% decreased risk of in-hospital mortality (RR 0.67, 95% CI 0.63-0.72), an absolute decrease in hospital length of stay (LOS) by 5.1 days (20.7 days vs. 15.6 days, P<0.001) and a $47,923 reduction in total hospital charges (P<0.001). Limitations included the study design (not a prospective randomized trial), and the possibility of other concurrent unmeasured quality initiatives taking place at the study sites, which might have contributed to improved outcomes.

Bottom line: Early sepsis intervention strategies in the form of a comprehensive continuous QI initiative can decrease mortality, hospital LOS, and cost in both tertiary-care and community hospitals.

Citation: Cannon CM, Holthaus CV, Zubrow MT, et al. The GENESIS project (GENeralized Early Sepsis Intervention Strategies): a multicenter quality improvement collaborative. J Intensive Care Med. 2012; Aug 17. doi:10.1177/0885066612453025.

Hypoglycemia Associated with Increased Mortality in the Critically Ill

Clinical question: Is hypoglycemia associated with mortality in critically ill patients?

Background: Initial studies suggested that intensive glucose control reduces mortality in surgical ICU patients and reduces morbidity in medical ICU patients, but further studies have not supported these findings. Recent literature shows conflicting results on the effects of intense glucose control in critically ill patients.

Study design: Post-hoc analysis of the NICE-SUGAR study database.

Setting: ICUs in 42 hospitals in Australia, New Zealand, and Canada.

Synopsis: The NICE-SUGAR study was a multicenter trial that randomized 6,104 ICU patients to intensive (glucose 80 to 108 mg/dL) or conventional glucose control (≤180 mg/dL). Patients were followed for 90 days or until death, with death being the primary end point. Severe hypoglycemia (<40 mg/dL) was recorded in 6.8% of patients in the intensive glucose control group versus 0.5% in the conventional group. The study showed that intensive glucose control was associated with increased mortality among adult ICU patients.

Using the NICE-SUGAR database, the authors conducted a Cox regression analysis to examine the associations between hypoglycemia and death. A total of 2,714 patients had moderate hypoglycemia (glucose 41 to 70 mg/dL), and 223 patients had severe hypoglycemia. The hazard ratio for mortality was 1.41 (95% CI 1.21-1.62, P<0.001) for patients with moderate hypoglycemia and 2.10 (95% CI 1.59-2.77, P<0.001) for severe hypoglycemia, compared to patients without hypoglycemia.

These findings show a strong association between mortality and hypoglycemia but do not prove causality. Hospitalists caring for ICU patients must be aware that hypoglycemia is associated with mortality and focus on avoiding hypoglycemia. The American Diabetes Association currently recommends a target blood glucose level of 140 to 180 mg/dL for most critically ill patients.

Bottom line: Hypoglycemia (glucose <70 mg/dL) is associated with increased risk of mortality in ICU patients.

Citation: Finfer S, Chittock DR, Su SY, et al. Hypoglycemia and risk of death in critically ill patients. New Engl J Med. 2012;367(12):1108-1118.

Increased Bleeding Risk for Cardiac Patients on Multiple Antithrombotic Drugs

Clinical question: Is there an increased risk of bleeding in atrial fibrillation patients treated with multiple antithrombotic agents following acute myocardial infarction (MI) or percutaneous coronary intervention (PCI)?

Background: Current treatment for atrial fibrillation patients with MI or PCI includes vitamin K antagonist (VKA) therapy to prevent stroke and antiplatelet agents to prevent further coronary events. There are inconsistent findings on the safety and efficacy of combined therapy with VKA, aspirin, and clopidogrel, specifically with regard to bleeding risk.

Study design: Retrospective cohort study.

Setting: Nationwide registry in Denmark.

Synopsis: Using the National Patient Registry in Denmark, 11,480 patients with atrial fibrillation who were admitted for MI or PCI were identified. Patients were grouped by medication regimen, including monotherapy (aspirin, clopidogrel, or VKA), dual therapy (dual antiplatelet or VKA+antiplatelet), or triple therapy (VKA+aspirin+clopidogrel). The primary outcome was nonfatal or fatal bleeding within one year.

Patients receiving triple therapy had the highest rate of bleeding, with a crude incidence of 14.2 events per 100 person-years. Patients treated with VKA+aspirin+clopidogel were significantly more likely than those on VKA+antiplatelet (HR 1.47, 95% CI 1.04-2.08) or dual antiplatelet (HR 2.20, 95% CI 1.58-3.08) treatment to have a bleeding event within 90 days, and similar trends were seen at 90 to 360 days. There was no significant difference in thromboembolic events among patients on VKA+aspirin+clopidogrel versus VKA+antiplatelet therapy.

Only bleeding events that required hospitalization were recorded, which might underestimate the bleeding risks of these regimens. Additionally, INR levels were not determined, which could impact both bleeding and thromboembolic outcomes.

However, this study does suggest that there are significant bleeding risks among patients treated with triple therapy. Hospitalists should weigh the risks of thromboembolic events with bleeding risks in patients with atrial fibrillation and MI/PCI, and only prescribe VKA+aspirin+clopidogrel with these risks in mind.

Bottom line: Immediate and continued bleeding risk is increased in patients with atrial fibrillation admitted with PCI or MI who are placed on triple antithrombotic therapy with VKA+aspirin+clopidogrel.

Citation: Lamberts M, Olesen JB, Ruwald MH, et al. Bleeding after initiation of multiple antithrombotic drugs, including triple therapy, in atrial fibrillation patients following myocardial infarction and coronary intervention. Circulation. 2012;126:1185-1193.

Hospitalist-Run Preoperative Clinic Improves Outcomes in Complex Surgical Patients

Clinical question: Do hospitalist-run preoperative clinics improve outcomes for medically complex patients undergoing noncardiac surgery compared to traditional anesthesiologist-run preoperative clinics?

Background: Studies of perioperative medical consultation have shown inconsistent effects on quality of care, but preoperative medical consultation has only been evaluated in the immediate preoperative period (one day prior to surgery or less). Little is known about the impact of involving hospitalists earlier in the preoperative period.

Study design: Retrospective, pre-post study.

Setting: Veterans Affairs Greater Los Angeles Healthcare System (VAGLAHS).

Synopsis: In July 2004, the VAGLAHS Preoperative Clinic transitioned from being anesthesiologist-run to hospitalist-run. Mid-level providers were trained on preoperative medical assessment, and patients were only evaluated by anesthesia staff on the day of surgery, after they had been deemed medically acceptable for surgery. All patients seen in the clinic from July 2003 to July 2005 were included in the study. Period A included patients evaluated when anesthesia staff supervised the clinic. Period B included patients evaluated during the first year of the hospitalist-run system.

There were 1,101 patients with inpatient surgeries in Period A, and 1,126 patients in Period B. Mean length of stay (LOS) decreased to 5.28 days during the hospitalist-run model from 9.87 days during the anesthesiologist-run model. LOS reductions were most notable in patients with ASA scores of 3 or higher; LOS reductions were not seen in an internal control of surgical patients who were not evaluated in the preoperative clinic. Inpatient mortality was also reduced in Period B compared with Period A, to 4 cases (0.36%) from 14 cases (1.27%) (P=0.0158). Specific processes that led to improved outcomes for patients in Period B could not be identified. The VA study setting might limit the generalizability of the results.

Bottom line: A hospitalist-run preoperative clinic was associated with decreased LOS and inpatient mortality compared with a traditional anesthesiologist-run clinic.

Citation: Vazirani S, Lankarani-Fard A, Lian LJ, Stelzner M, Asch SM. Preoperative processes and outcomes after implementation of a hospitalist-run preoperative clinic. J Hosp Med. 2012 Sep 7. doi:10.1002/jhm.1968.

Delirium after Cardiac Surgery Associated with Prolonged Cognitive Impairment

Clinical question: Is postoperative delirium associated with decreased cognitive function in the first year after cardiac surgery?

Background: In general populations, delirium has been associated with long-term decline in cognitive ability. Delirium and cognitive dysfunction are both common following cardiac surgery, but the effects of postoperative delirium on the trajectory of cognitive function over time is unclear.

Study design: Prospective cohort study.

Setting: Two academic medical centers and a Veterans Administration hospital.

Synopsis: Two hundred twenty-five patients aged 60 or older who were scheduled to undergo coronary artery bypass grafting or valve replacement surgery were included. Patients underwent preoperative assessment cognitive function with the use of the Mini-Mental State Examination (MMSE). Starting on postoperative Day 2, patients underwent daily assessment for delirium. After discharge, cognitive function was reassessed at months one, six, and 12.

Postoperative delirium occurred in 103 patients (46%). Patients with delirium were older, had higher comorbidity scores, and had lower MMSE scores at baseline. Among the overall study population, adjusted MMSE scores dropped 4.6 points from baseline to postoperative Day 2, then were observed to increase by approximately one point per day during postoperative days 3 to 5 with minimal change thereafter. Patients with delirium had greater decrease in cognitive function in the immediate postoperative period compared to patients without delirium (7.7 points vs. 2.1, P<0.001).

Patients without delirium returned to their baseline cognitive ability by one month postoperatively, while patients who had delirium were still making gains up to six months post-operatively, never returning to baseline level of function by one year. Unmeasured confounders and uncertain sensitivity of the MMSE to detect mild cognitive impairment might limit these findings.

Bottom line: Cognitive function decreases in the immediate postoperative period following cardiac surgery. Compared to patients without delirium, patients with delirium experience more dramatic and prolonged cognitive impairment postoperatively, without returning to their preoperative level of cognitive function at one year.

Citation: Saczynski JS, Marcantonio ER, Quach L, et al. Cognitive trajectories after postoperative delirium. New Engl J Med. 2012;367:30-39.

Benefits of Resuming Anticoagulation after GI Bleed Outweigh Risks for Most Patients

Clinical question: In warfarin-treated patients who have experienced gastrointestinal (GI) bleeding, what are the patterns of restarting warfarin therapy and the incidence of thrombosis, recurrent GI bleed, and death in the 90 days following index bleed?

Background: In warfarin-treated patients who experience GI bleeding, warfarin is often temporarily held or permanently discontinued, placing patients at increased risk for developing thromboembolism. Little is known about the risks, benefits, and timing of restarting warfarin in this patient population.

Study design: Retrospective cohort study.

Setting: Kaiser Permanente Colorado.

Synopsis: Using clinical and administrative databases, 442 patients who presented with GI bleeding while receiving warfarin therapy were identified. Patients were grouped by whether they resumed warfarin (n=260, including 41 patients in whom anticoagulation was never interrupted), or did not resume warfarin therapy (n=182) in the 90 days following index GI bleed. Patients with prosthetic heart valves or GI bleeding localized to the rectum/anus were more commonly restarted on warfarin, whereas older patients and those in whom the source of bleeding was not identified were less likely to be restarted on warfarin therapy.

Restarting warfarin therapy after index GI bleed was associated with lower risk of thrombosis (HR 0.05, 95% CI 0.01-0.58) and death from any cause (HR 0.31, 95% CI 0.15-0.62), and it was not associated with a significant increase in risk for recurrent GI bleed (HR 1.32, 95% CI 0.50-3.57).

The authors concluded that for many patients who experience a warfarin-associated GI bleed, the benefits of restarting warfarin therapy outweigh the risks. No conclusions were made regarding the optimal timing of resuming therapy. Limitations included the use of administrative data and inability to determine the potential influence of aspirin use on outcomes.

Bottom line: Resuming warfarin in the 90 days following a warfarin-associated GI bleed is associated with decreased risk of thrombosis and death without increased risk for recurrent GI bleed.

Citation: Witt DM, Delate T, Garcia DA, et al. Risk of thromboembolism, recurrent hemorrhage, and death after warfarin therapy interruption for gastrointestinal tract bleeding. Arch Intern Med. 2012 Sep 12. doi:10.1001/archinternmed.2012.4261.

Preoperative Hyponatremia Associated with Increased Risk for Perioperative Complications and Mortality

Clinical question: Is preoperative hyponatremia an indicator of perioperative morbidity and mortality?

Background: Hyponatremia is a common diagnosis in the hospital setting and is associated with adverse outcomes, even in mild cases. However, it is unclear if this association exists in surgical patients when detected preoperatively.

Study design: Retrospective cohort study.

Setting: Academic and community hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP).

Synopsis: A total of 75,423 adult patients with hyponatremia (sodium <135 mEq/L) who were undergoing major surgery were compared to 888,840 patients with normal preoperative sodium levels over a six-year period. The primary outcome was 30-day mortality. Secondary outcomes included postoperative major coronary events, stroke, wound infection, pneumonia, and length of stay (LOS).

Compared to patients with normal sodium levels, those with preoperative hyponatremia had higher rates of perioperative mortality (5.2% vs. 1.3%; adjusted odds ratio 1.44, 95% CI 1.38-1.50), with increased risk that correlated with increasing severity of hyponatremia. Association with postoperative mortality was particularly strong among hyponatremic patients with ASA scores of 1 or 2 and those undergoing nonemergency surgery.

Patients with preoperative hyponatremia were also found to have increased risk for all postoperative complications evaluated, with the exception of stroke. Limitations included the potential for unmeasured confounders and not being able to account for the role of medications used perioperatively. Research is needed to determine whether correcting preoperative hyponatremia lessens the risk of mortality and other postoperative complications.

Bottom line: Among patients undergoing major surgery, preoperative hyponatremia is a predictor of postoperative 30-day mortality and morbidity.

Citation: Leung AA, McAlister FA, Rogers SO, et al. Preoperative hyponatremia and perioperative complications. Arch Intern Med. 2012;172:1-8.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Interventions that improve discharge handovers reviewed
2. Duration of in-hospital cardiac resuscitation and survival rates
3. Early sepsis intervention strategies to decrease mortality risk
4. Hypoglycemia linked to increased mortality in critically ill
5. Increased bleeding risk for cardiac patients
6. Hospital-run vs. anesthesiologist-run preoperative clinics
7. Postoperative delirium and cognitive impairment in cardiac patients
8. Benefits of resuming anticoagulants after GI bleeding
9. Preoperative hyponatremia and risk of perioperative mortality

Systematic Review Highlights Several Interventions That Improve Discharge Handovers

Clinical question: Do interventions to improve patient handovers at discharge have positive effects on patient care?

Background: The transition from hospital to primary care is often suboptimal and has been associated with unfavorable outcomes, including hospital readmission, increased healthcare utilization, and adverse drug events post-discharge. This review sought to characterize different types of interventions aimed at improving discharge handovers and to evaluate their effects.

Study design: Systematic review of randomized controlled trials.

Setting: Studies published from January 1990 to March 2011.

Synopsis: Review of published databases identified 36 randomized controlled studies on interventions to improve discharge handovers. Studies were blindly evaluated by two reviewers on quality, interventions, and outcomes. There was significant heterogeneity in interventions and outcomes; thus, statistical analysis was not possible. Most studies evaluated multicomponent interventions and had more than one outcome measure.

Of the 36 studies reviewed, 25 reported statistically significant improvements in outcomes, including reduced hospital utilization and improved continuity of care. Effective interventions included medication reconciliation; structured discharge information (facilitated by electronic resources); multidisciplinary discharge planning; shared involvement in arranging care between inpatient and outpatient physicians; and Web-based access to discharge information by the outpatient provider.

The complexity of the interventions and the heterogeneity of reported results did not allow for firm conclusions to be drawn regarding which specific interventions had the strongest effects.

Bottom line: Interventions that target the quality and safety of handovers between hospital and outpatient providers at discharge can significantly reduce hospital utilization and improve continuity of care.

Citation: Hesselink G, Schoonhoven L, Barach P, et al. Improving patient handovers from hospital to primary care: a systematic review. Ann Intern Med. 2012;157:417-428.

Longer Duration of In-Hospital Cardiac Resuscitation Associated with Increased Survival

Clinical question: Are prolonged cardiac resuscitation efforts associated with improved outcomes?

Background: There is little evidence or guidelines on how long to maintain resuscitative efforts during in-hospital cardiac arrest, leading to variation in practice. This study characterized patterns of resuscitation duration and relationship to the return of spontaneous circulation and survival to discharge.

Study design: Retrospective observational study.

Setting: Four hundred thirty-five U.S. hospitals reporting data to the American Heart Association’s Get With The Guidelines: Resuscitation registry.

Synopsis: Using duration of resuscitation in nonsurvivors as a surrogate for the tendency of a facility to perform prolonged efforts, hospitals were divided into quartiles. Overall, of 64,339 patients in the registry, 31,198 (48.5%) had return of circulation and 9,912 (15.4%) survived to discharge. Resuscitative efforts in nonsurvivors ranged from a median of 16 to 25 minutes between the lowest and highest quartiles.

There was a stepwise increase in the likelihood for patients to have return of spontaneous circulation and to survive to discharge between each quartile. Specifically, comparing shortest to longest, there was a significant adjusted odds ratio of 1.12 for both the return of circulation (P<0.0001) and survival to discharge (P=0.021). The survival benefit was most apparent for those with pulseless electrical activity or asystole as initial rhythms, as compared to ventricular tachycardia or fibrillation.

Limitations included the study’s observational design, which meant causality could not be determined. Additionally, the study did not account for the quality of resuscitative efforts (e.g. depth of chest compressions, adherence with guidelines), which might have influenced outcomes. Importantly, the study looked at survival to discharge, but it did not evaluate long-term survival or functional status post-discharge, which might better reflect the success of resuscitation.

Bottom line: Prolonged resuscitative efforts were observed to be associated with increased likelihood of return of spontaneous circulation and survival to discharge; this data might provide clinical guidance in determining when to stop resuscitation efforts.

Citation: Goldberger ZD, Chan PS, Berg RA, et al. Duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study. Lancet. 2012;380:1473-1481.

Early Sepsis Intervention Strategies Decrease Mortality, Length of Stay, and Cost

Clinical question: For patients with sepsis or septic shock, what is the impact of a real-time comprehensive continuous quality-improvement (QI) initiative on in-hospital mortality, morbidity, and healthcare resource utilization in community and tertiary-care hospitals in the U.S.?

Background: Multiple single-center trials have demonstrated that early sepsis intervention strategies (early goal-directed therapy, resuscitation bundles) improve in-hospital mortality. Little is known about the effectiveness of incorporating these strategies into a real-time continuous QI initiative and implementing interventions across multiple sites simultaneously.

Study design: Pre-post at some sites and concurrent implementation design at other sites.

Setting: Five community and six-tertiary care U.S. hospitals.

Synopsis: The GENeralized Early Sepsis Intervention Strategies (GENESIS) project was a CQI initiative that combined several QI concepts with validated early sepsis interventions known as resuscitation bundles (RB). Continuous QI was implemented on patients with severe sepsis or septic shock in both before and after designs (eight hospitals), and in concurrent designs (three hospitals). The control group was comprised of historical controls treated before GENESIS and patients with incomplete implementation of RB, totaling 1,554 patients. The treatment group included patients treated after GENESIS and those with complete RB compliance, totaling 4,801 patients.

Compared with the control group, patients in the treatment group had a 33% decreased risk of in-hospital mortality (RR 0.67, 95% CI 0.63-0.72), an absolute decrease in hospital length of stay (LOS) by 5.1 days (20.7 days vs. 15.6 days, P<0.001) and a $47,923 reduction in total hospital charges (P<0.001). Limitations included the study design (not a prospective randomized trial), and the possibility of other concurrent unmeasured quality initiatives taking place at the study sites, which might have contributed to improved outcomes.

Bottom line: Early sepsis intervention strategies in the form of a comprehensive continuous QI initiative can decrease mortality, hospital LOS, and cost in both tertiary-care and community hospitals.

Citation: Cannon CM, Holthaus CV, Zubrow MT, et al. The GENESIS project (GENeralized Early Sepsis Intervention Strategies): a multicenter quality improvement collaborative. J Intensive Care Med. 2012; Aug 17. doi:10.1177/0885066612453025.

Hypoglycemia Associated with Increased Mortality in the Critically Ill

Clinical question: Is hypoglycemia associated with mortality in critically ill patients?

Background: Initial studies suggested that intensive glucose control reduces mortality in surgical ICU patients and reduces morbidity in medical ICU patients, but further studies have not supported these findings. Recent literature shows conflicting results on the effects of intense glucose control in critically ill patients.

Study design: Post-hoc analysis of the NICE-SUGAR study database.

Setting: ICUs in 42 hospitals in Australia, New Zealand, and Canada.

Synopsis: The NICE-SUGAR study was a multicenter trial that randomized 6,104 ICU patients to intensive (glucose 80 to 108 mg/dL) or conventional glucose control (≤180 mg/dL). Patients were followed for 90 days or until death, with death being the primary end point. Severe hypoglycemia (<40 mg/dL) was recorded in 6.8% of patients in the intensive glucose control group versus 0.5% in the conventional group. The study showed that intensive glucose control was associated with increased mortality among adult ICU patients.

Using the NICE-SUGAR database, the authors conducted a Cox regression analysis to examine the associations between hypoglycemia and death. A total of 2,714 patients had moderate hypoglycemia (glucose 41 to 70 mg/dL), and 223 patients had severe hypoglycemia. The hazard ratio for mortality was 1.41 (95% CI 1.21-1.62, P<0.001) for patients with moderate hypoglycemia and 2.10 (95% CI 1.59-2.77, P<0.001) for severe hypoglycemia, compared to patients without hypoglycemia.

These findings show a strong association between mortality and hypoglycemia but do not prove causality. Hospitalists caring for ICU patients must be aware that hypoglycemia is associated with mortality and focus on avoiding hypoglycemia. The American Diabetes Association currently recommends a target blood glucose level of 140 to 180 mg/dL for most critically ill patients.

Bottom line: Hypoglycemia (glucose <70 mg/dL) is associated with increased risk of mortality in ICU patients.

Citation: Finfer S, Chittock DR, Su SY, et al. Hypoglycemia and risk of death in critically ill patients. New Engl J Med. 2012;367(12):1108-1118.

Increased Bleeding Risk for Cardiac Patients on Multiple Antithrombotic Drugs

Clinical question: Is there an increased risk of bleeding in atrial fibrillation patients treated with multiple antithrombotic agents following acute myocardial infarction (MI) or percutaneous coronary intervention (PCI)?

Background: Current treatment for atrial fibrillation patients with MI or PCI includes vitamin K antagonist (VKA) therapy to prevent stroke and antiplatelet agents to prevent further coronary events. There are inconsistent findings on the safety and efficacy of combined therapy with VKA, aspirin, and clopidogrel, specifically with regard to bleeding risk.

Study design: Retrospective cohort study.

Setting: Nationwide registry in Denmark.

Synopsis: Using the National Patient Registry in Denmark, 11,480 patients with atrial fibrillation who were admitted for MI or PCI were identified. Patients were grouped by medication regimen, including monotherapy (aspirin, clopidogrel, or VKA), dual therapy (dual antiplatelet or VKA+antiplatelet), or triple therapy (VKA+aspirin+clopidogrel). The primary outcome was nonfatal or fatal bleeding within one year.

Patients receiving triple therapy had the highest rate of bleeding, with a crude incidence of 14.2 events per 100 person-years. Patients treated with VKA+aspirin+clopidogel were significantly more likely than those on VKA+antiplatelet (HR 1.47, 95% CI 1.04-2.08) or dual antiplatelet (HR 2.20, 95% CI 1.58-3.08) treatment to have a bleeding event within 90 days, and similar trends were seen at 90 to 360 days. There was no significant difference in thromboembolic events among patients on VKA+aspirin+clopidogrel versus VKA+antiplatelet therapy.

Only bleeding events that required hospitalization were recorded, which might underestimate the bleeding risks of these regimens. Additionally, INR levels were not determined, which could impact both bleeding and thromboembolic outcomes.

However, this study does suggest that there are significant bleeding risks among patients treated with triple therapy. Hospitalists should weigh the risks of thromboembolic events with bleeding risks in patients with atrial fibrillation and MI/PCI, and only prescribe VKA+aspirin+clopidogrel with these risks in mind.

Bottom line: Immediate and continued bleeding risk is increased in patients with atrial fibrillation admitted with PCI or MI who are placed on triple antithrombotic therapy with VKA+aspirin+clopidogrel.

Citation: Lamberts M, Olesen JB, Ruwald MH, et al. Bleeding after initiation of multiple antithrombotic drugs, including triple therapy, in atrial fibrillation patients following myocardial infarction and coronary intervention. Circulation. 2012;126:1185-1193.

Hospitalist-Run Preoperative Clinic Improves Outcomes in Complex Surgical Patients

Clinical question: Do hospitalist-run preoperative clinics improve outcomes for medically complex patients undergoing noncardiac surgery compared to traditional anesthesiologist-run preoperative clinics?

Background: Studies of perioperative medical consultation have shown inconsistent effects on quality of care, but preoperative medical consultation has only been evaluated in the immediate preoperative period (one day prior to surgery or less). Little is known about the impact of involving hospitalists earlier in the preoperative period.

Study design: Retrospective, pre-post study.

Setting: Veterans Affairs Greater Los Angeles Healthcare System (VAGLAHS).

Synopsis: In July 2004, the VAGLAHS Preoperative Clinic transitioned from being anesthesiologist-run to hospitalist-run. Mid-level providers were trained on preoperative medical assessment, and patients were only evaluated by anesthesia staff on the day of surgery, after they had been deemed medically acceptable for surgery. All patients seen in the clinic from July 2003 to July 2005 were included in the study. Period A included patients evaluated when anesthesia staff supervised the clinic. Period B included patients evaluated during the first year of the hospitalist-run system.

There were 1,101 patients with inpatient surgeries in Period A, and 1,126 patients in Period B. Mean length of stay (LOS) decreased to 5.28 days during the hospitalist-run model from 9.87 days during the anesthesiologist-run model. LOS reductions were most notable in patients with ASA scores of 3 or higher; LOS reductions were not seen in an internal control of surgical patients who were not evaluated in the preoperative clinic. Inpatient mortality was also reduced in Period B compared with Period A, to 4 cases (0.36%) from 14 cases (1.27%) (P=0.0158). Specific processes that led to improved outcomes for patients in Period B could not be identified. The VA study setting might limit the generalizability of the results.

Bottom line: A hospitalist-run preoperative clinic was associated with decreased LOS and inpatient mortality compared with a traditional anesthesiologist-run clinic.

Citation: Vazirani S, Lankarani-Fard A, Lian LJ, Stelzner M, Asch SM. Preoperative processes and outcomes after implementation of a hospitalist-run preoperative clinic. J Hosp Med. 2012 Sep 7. doi:10.1002/jhm.1968.

Delirium after Cardiac Surgery Associated with Prolonged Cognitive Impairment

Clinical question: Is postoperative delirium associated with decreased cognitive function in the first year after cardiac surgery?

Background: In general populations, delirium has been associated with long-term decline in cognitive ability. Delirium and cognitive dysfunction are both common following cardiac surgery, but the effects of postoperative delirium on the trajectory of cognitive function over time is unclear.

Study design: Prospective cohort study.

Setting: Two academic medical centers and a Veterans Administration hospital.

Synopsis: Two hundred twenty-five patients aged 60 or older who were scheduled to undergo coronary artery bypass grafting or valve replacement surgery were included. Patients underwent preoperative assessment cognitive function with the use of the Mini-Mental State Examination (MMSE). Starting on postoperative Day 2, patients underwent daily assessment for delirium. After discharge, cognitive function was reassessed at months one, six, and 12.

Postoperative delirium occurred in 103 patients (46%). Patients with delirium were older, had higher comorbidity scores, and had lower MMSE scores at baseline. Among the overall study population, adjusted MMSE scores dropped 4.6 points from baseline to postoperative Day 2, then were observed to increase by approximately one point per day during postoperative days 3 to 5 with minimal change thereafter. Patients with delirium had greater decrease in cognitive function in the immediate postoperative period compared to patients without delirium (7.7 points vs. 2.1, P<0.001).

Patients without delirium returned to their baseline cognitive ability by one month postoperatively, while patients who had delirium were still making gains up to six months post-operatively, never returning to baseline level of function by one year. Unmeasured confounders and uncertain sensitivity of the MMSE to detect mild cognitive impairment might limit these findings.

Bottom line: Cognitive function decreases in the immediate postoperative period following cardiac surgery. Compared to patients without delirium, patients with delirium experience more dramatic and prolonged cognitive impairment postoperatively, without returning to their preoperative level of cognitive function at one year.

Citation: Saczynski JS, Marcantonio ER, Quach L, et al. Cognitive trajectories after postoperative delirium. New Engl J Med. 2012;367:30-39.

Benefits of Resuming Anticoagulation after GI Bleed Outweigh Risks for Most Patients

Clinical question: In warfarin-treated patients who have experienced gastrointestinal (GI) bleeding, what are the patterns of restarting warfarin therapy and the incidence of thrombosis, recurrent GI bleed, and death in the 90 days following index bleed?

Background: In warfarin-treated patients who experience GI bleeding, warfarin is often temporarily held or permanently discontinued, placing patients at increased risk for developing thromboembolism. Little is known about the risks, benefits, and timing of restarting warfarin in this patient population.

Study design: Retrospective cohort study.

Setting: Kaiser Permanente Colorado.

Synopsis: Using clinical and administrative databases, 442 patients who presented with GI bleeding while receiving warfarin therapy were identified. Patients were grouped by whether they resumed warfarin (n=260, including 41 patients in whom anticoagulation was never interrupted), or did not resume warfarin therapy (n=182) in the 90 days following index GI bleed. Patients with prosthetic heart valves or GI bleeding localized to the rectum/anus were more commonly restarted on warfarin, whereas older patients and those in whom the source of bleeding was not identified were less likely to be restarted on warfarin therapy.

Restarting warfarin therapy after index GI bleed was associated with lower risk of thrombosis (HR 0.05, 95% CI 0.01-0.58) and death from any cause (HR 0.31, 95% CI 0.15-0.62), and it was not associated with a significant increase in risk for recurrent GI bleed (HR 1.32, 95% CI 0.50-3.57).

The authors concluded that for many patients who experience a warfarin-associated GI bleed, the benefits of restarting warfarin therapy outweigh the risks. No conclusions were made regarding the optimal timing of resuming therapy. Limitations included the use of administrative data and inability to determine the potential influence of aspirin use on outcomes.

Bottom line: Resuming warfarin in the 90 days following a warfarin-associated GI bleed is associated with decreased risk of thrombosis and death without increased risk for recurrent GI bleed.

Citation: Witt DM, Delate T, Garcia DA, et al. Risk of thromboembolism, recurrent hemorrhage, and death after warfarin therapy interruption for gastrointestinal tract bleeding. Arch Intern Med. 2012 Sep 12. doi:10.1001/archinternmed.2012.4261.

Preoperative Hyponatremia Associated with Increased Risk for Perioperative Complications and Mortality

Clinical question: Is preoperative hyponatremia an indicator of perioperative morbidity and mortality?

Background: Hyponatremia is a common diagnosis in the hospital setting and is associated with adverse outcomes, even in mild cases. However, it is unclear if this association exists in surgical patients when detected preoperatively.

Study design: Retrospective cohort study.

Setting: Academic and community hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP).

Synopsis: A total of 75,423 adult patients with hyponatremia (sodium <135 mEq/L) who were undergoing major surgery were compared to 888,840 patients with normal preoperative sodium levels over a six-year period. The primary outcome was 30-day mortality. Secondary outcomes included postoperative major coronary events, stroke, wound infection, pneumonia, and length of stay (LOS).

Compared to patients with normal sodium levels, those with preoperative hyponatremia had higher rates of perioperative mortality (5.2% vs. 1.3%; adjusted odds ratio 1.44, 95% CI 1.38-1.50), with increased risk that correlated with increasing severity of hyponatremia. Association with postoperative mortality was particularly strong among hyponatremic patients with ASA scores of 1 or 2 and those undergoing nonemergency surgery.

Patients with preoperative hyponatremia were also found to have increased risk for all postoperative complications evaluated, with the exception of stroke. Limitations included the potential for unmeasured confounders and not being able to account for the role of medications used perioperatively. Research is needed to determine whether correcting preoperative hyponatremia lessens the risk of mortality and other postoperative complications.

Bottom line: Among patients undergoing major surgery, preoperative hyponatremia is a predictor of postoperative 30-day mortality and morbidity.

Citation: Leung AA, McAlister FA, Rogers SO, et al. Preoperative hyponatremia and perioperative complications. Arch Intern Med. 2012;172:1-8.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Interventions that improve discharge handovers reviewed
2. Duration of in-hospital cardiac resuscitation and survival rates
3. Early sepsis intervention strategies to decrease mortality risk
4. Hypoglycemia linked to increased mortality in critically ill
5. Increased bleeding risk for cardiac patients
6. Hospital-run vs. anesthesiologist-run preoperative clinics
7. Postoperative delirium and cognitive impairment in cardiac patients
8. Benefits of resuming anticoagulants after GI bleeding
9. Preoperative hyponatremia and risk of perioperative mortality

Systematic Review Highlights Several Interventions That Improve Discharge Handovers

Clinical question: Do interventions to improve patient handovers at discharge have positive effects on patient care?

Background: The transition from hospital to primary care is often suboptimal and has been associated with unfavorable outcomes, including hospital readmission, increased healthcare utilization, and adverse drug events post-discharge. This review sought to characterize different types of interventions aimed at improving discharge handovers and to evaluate their effects.

Study design: Systematic review of randomized controlled trials.

Setting: Studies published from January 1990 to March 2011.

Synopsis: Review of published databases identified 36 randomized controlled studies on interventions to improve discharge handovers. Studies were blindly evaluated by two reviewers on quality, interventions, and outcomes. There was significant heterogeneity in interventions and outcomes; thus, statistical analysis was not possible. Most studies evaluated multicomponent interventions and had more than one outcome measure.

Of the 36 studies reviewed, 25 reported statistically significant improvements in outcomes, including reduced hospital utilization and improved continuity of care. Effective interventions included medication reconciliation; structured discharge information (facilitated by electronic resources); multidisciplinary discharge planning; shared involvement in arranging care between inpatient and outpatient physicians; and Web-based access to discharge information by the outpatient provider.

The complexity of the interventions and the heterogeneity of reported results did not allow for firm conclusions to be drawn regarding which specific interventions had the strongest effects.

Bottom line: Interventions that target the quality and safety of handovers between hospital and outpatient providers at discharge can significantly reduce hospital utilization and improve continuity of care.

Citation: Hesselink G, Schoonhoven L, Barach P, et al. Improving patient handovers from hospital to primary care: a systematic review. Ann Intern Med. 2012;157:417-428.

Longer Duration of In-Hospital Cardiac Resuscitation Associated with Increased Survival

Clinical question: Are prolonged cardiac resuscitation efforts associated with improved outcomes?

Background: There is little evidence or guidelines on how long to maintain resuscitative efforts during in-hospital cardiac arrest, leading to variation in practice. This study characterized patterns of resuscitation duration and relationship to the return of spontaneous circulation and survival to discharge.

Study design: Retrospective observational study.

Setting: Four hundred thirty-five U.S. hospitals reporting data to the American Heart Association’s Get With The Guidelines: Resuscitation registry.

Synopsis: Using duration of resuscitation in nonsurvivors as a surrogate for the tendency of a facility to perform prolonged efforts, hospitals were divided into quartiles. Overall, of 64,339 patients in the registry, 31,198 (48.5%) had return of circulation and 9,912 (15.4%) survived to discharge. Resuscitative efforts in nonsurvivors ranged from a median of 16 to 25 minutes between the lowest and highest quartiles.

There was a stepwise increase in the likelihood for patients to have return of spontaneous circulation and to survive to discharge between each quartile. Specifically, comparing shortest to longest, there was a significant adjusted odds ratio of 1.12 for both the return of circulation (P<0.0001) and survival to discharge (P=0.021). The survival benefit was most apparent for those with pulseless electrical activity or asystole as initial rhythms, as compared to ventricular tachycardia or fibrillation.

Limitations included the study’s observational design, which meant causality could not be determined. Additionally, the study did not account for the quality of resuscitative efforts (e.g. depth of chest compressions, adherence with guidelines), which might have influenced outcomes. Importantly, the study looked at survival to discharge, but it did not evaluate long-term survival or functional status post-discharge, which might better reflect the success of resuscitation.

Bottom line: Prolonged resuscitative efforts were observed to be associated with increased likelihood of return of spontaneous circulation and survival to discharge; this data might provide clinical guidance in determining when to stop resuscitation efforts.

Citation: Goldberger ZD, Chan PS, Berg RA, et al. Duration of resuscitation efforts and survival after in-hospital cardiac arrest: an observational study. Lancet. 2012;380:1473-1481.

Early Sepsis Intervention Strategies Decrease Mortality, Length of Stay, and Cost

Clinical question: For patients with sepsis or septic shock, what is the impact of a real-time comprehensive continuous quality-improvement (QI) initiative on in-hospital mortality, morbidity, and healthcare resource utilization in community and tertiary-care hospitals in the U.S.?

Background: Multiple single-center trials have demonstrated that early sepsis intervention strategies (early goal-directed therapy, resuscitation bundles) improve in-hospital mortality. Little is known about the effectiveness of incorporating these strategies into a real-time continuous QI initiative and implementing interventions across multiple sites simultaneously.

Study design: Pre-post at some sites and concurrent implementation design at other sites.

Setting: Five community and six-tertiary care U.S. hospitals.

Synopsis: The GENeralized Early Sepsis Intervention Strategies (GENESIS) project was a CQI initiative that combined several QI concepts with validated early sepsis interventions known as resuscitation bundles (RB). Continuous QI was implemented on patients with severe sepsis or septic shock in both before and after designs (eight hospitals), and in concurrent designs (three hospitals). The control group was comprised of historical controls treated before GENESIS and patients with incomplete implementation of RB, totaling 1,554 patients. The treatment group included patients treated after GENESIS and those with complete RB compliance, totaling 4,801 patients.

Compared with the control group, patients in the treatment group had a 33% decreased risk of in-hospital mortality (RR 0.67, 95% CI 0.63-0.72), an absolute decrease in hospital length of stay (LOS) by 5.1 days (20.7 days vs. 15.6 days, P<0.001) and a $47,923 reduction in total hospital charges (P<0.001). Limitations included the study design (not a prospective randomized trial), and the possibility of other concurrent unmeasured quality initiatives taking place at the study sites, which might have contributed to improved outcomes.

Bottom line: Early sepsis intervention strategies in the form of a comprehensive continuous QI initiative can decrease mortality, hospital LOS, and cost in both tertiary-care and community hospitals.

Citation: Cannon CM, Holthaus CV, Zubrow MT, et al. The GENESIS project (GENeralized Early Sepsis Intervention Strategies): a multicenter quality improvement collaborative. J Intensive Care Med. 2012; Aug 17. doi:10.1177/0885066612453025.

Hypoglycemia Associated with Increased Mortality in the Critically Ill

Clinical question: Is hypoglycemia associated with mortality in critically ill patients?

Background: Initial studies suggested that intensive glucose control reduces mortality in surgical ICU patients and reduces morbidity in medical ICU patients, but further studies have not supported these findings. Recent literature shows conflicting results on the effects of intense glucose control in critically ill patients.

Study design: Post-hoc analysis of the NICE-SUGAR study database.

Setting: ICUs in 42 hospitals in Australia, New Zealand, and Canada.

Synopsis: The NICE-SUGAR study was a multicenter trial that randomized 6,104 ICU patients to intensive (glucose 80 to 108 mg/dL) or conventional glucose control (≤180 mg/dL). Patients were followed for 90 days or until death, with death being the primary end point. Severe hypoglycemia (<40 mg/dL) was recorded in 6.8% of patients in the intensive glucose control group versus 0.5% in the conventional group. The study showed that intensive glucose control was associated with increased mortality among adult ICU patients.

Using the NICE-SUGAR database, the authors conducted a Cox regression analysis to examine the associations between hypoglycemia and death. A total of 2,714 patients had moderate hypoglycemia (glucose 41 to 70 mg/dL), and 223 patients had severe hypoglycemia. The hazard ratio for mortality was 1.41 (95% CI 1.21-1.62, P<0.001) for patients with moderate hypoglycemia and 2.10 (95% CI 1.59-2.77, P<0.001) for severe hypoglycemia, compared to patients without hypoglycemia.

These findings show a strong association between mortality and hypoglycemia but do not prove causality. Hospitalists caring for ICU patients must be aware that hypoglycemia is associated with mortality and focus on avoiding hypoglycemia. The American Diabetes Association currently recommends a target blood glucose level of 140 to 180 mg/dL for most critically ill patients.

Bottom line: Hypoglycemia (glucose <70 mg/dL) is associated with increased risk of mortality in ICU patients.

Citation: Finfer S, Chittock DR, Su SY, et al. Hypoglycemia and risk of death in critically ill patients. New Engl J Med. 2012;367(12):1108-1118.

Increased Bleeding Risk for Cardiac Patients on Multiple Antithrombotic Drugs

Clinical question: Is there an increased risk of bleeding in atrial fibrillation patients treated with multiple antithrombotic agents following acute myocardial infarction (MI) or percutaneous coronary intervention (PCI)?

Background: Current treatment for atrial fibrillation patients with MI or PCI includes vitamin K antagonist (VKA) therapy to prevent stroke and antiplatelet agents to prevent further coronary events. There are inconsistent findings on the safety and efficacy of combined therapy with VKA, aspirin, and clopidogrel, specifically with regard to bleeding risk.

Study design: Retrospective cohort study.

Setting: Nationwide registry in Denmark.

Synopsis: Using the National Patient Registry in Denmark, 11,480 patients with atrial fibrillation who were admitted for MI or PCI were identified. Patients were grouped by medication regimen, including monotherapy (aspirin, clopidogrel, or VKA), dual therapy (dual antiplatelet or VKA+antiplatelet), or triple therapy (VKA+aspirin+clopidogrel). The primary outcome was nonfatal or fatal bleeding within one year.

Patients receiving triple therapy had the highest rate of bleeding, with a crude incidence of 14.2 events per 100 person-years. Patients treated with VKA+aspirin+clopidogel were significantly more likely than those on VKA+antiplatelet (HR 1.47, 95% CI 1.04-2.08) or dual antiplatelet (HR 2.20, 95% CI 1.58-3.08) treatment to have a bleeding event within 90 days, and similar trends were seen at 90 to 360 days. There was no significant difference in thromboembolic events among patients on VKA+aspirin+clopidogrel versus VKA+antiplatelet therapy.

Only bleeding events that required hospitalization were recorded, which might underestimate the bleeding risks of these regimens. Additionally, INR levels were not determined, which could impact both bleeding and thromboembolic outcomes.

However, this study does suggest that there are significant bleeding risks among patients treated with triple therapy. Hospitalists should weigh the risks of thromboembolic events with bleeding risks in patients with atrial fibrillation and MI/PCI, and only prescribe VKA+aspirin+clopidogrel with these risks in mind.

Bottom line: Immediate and continued bleeding risk is increased in patients with atrial fibrillation admitted with PCI or MI who are placed on triple antithrombotic therapy with VKA+aspirin+clopidogrel.

Citation: Lamberts M, Olesen JB, Ruwald MH, et al. Bleeding after initiation of multiple antithrombotic drugs, including triple therapy, in atrial fibrillation patients following myocardial infarction and coronary intervention. Circulation. 2012;126:1185-1193.

Hospitalist-Run Preoperative Clinic Improves Outcomes in Complex Surgical Patients

Clinical question: Do hospitalist-run preoperative clinics improve outcomes for medically complex patients undergoing noncardiac surgery compared to traditional anesthesiologist-run preoperative clinics?

Background: Studies of perioperative medical consultation have shown inconsistent effects on quality of care, but preoperative medical consultation has only been evaluated in the immediate preoperative period (one day prior to surgery or less). Little is known about the impact of involving hospitalists earlier in the preoperative period.

Study design: Retrospective, pre-post study.

Setting: Veterans Affairs Greater Los Angeles Healthcare System (VAGLAHS).

Synopsis: In July 2004, the VAGLAHS Preoperative Clinic transitioned from being anesthesiologist-run to hospitalist-run. Mid-level providers were trained on preoperative medical assessment, and patients were only evaluated by anesthesia staff on the day of surgery, after they had been deemed medically acceptable for surgery. All patients seen in the clinic from July 2003 to July 2005 were included in the study. Period A included patients evaluated when anesthesia staff supervised the clinic. Period B included patients evaluated during the first year of the hospitalist-run system.

There were 1,101 patients with inpatient surgeries in Period A, and 1,126 patients in Period B. Mean length of stay (LOS) decreased to 5.28 days during the hospitalist-run model from 9.87 days during the anesthesiologist-run model. LOS reductions were most notable in patients with ASA scores of 3 or higher; LOS reductions were not seen in an internal control of surgical patients who were not evaluated in the preoperative clinic. Inpatient mortality was also reduced in Period B compared with Period A, to 4 cases (0.36%) from 14 cases (1.27%) (P=0.0158). Specific processes that led to improved outcomes for patients in Period B could not be identified. The VA study setting might limit the generalizability of the results.

Bottom line: A hospitalist-run preoperative clinic was associated with decreased LOS and inpatient mortality compared with a traditional anesthesiologist-run clinic.

Citation: Vazirani S, Lankarani-Fard A, Lian LJ, Stelzner M, Asch SM. Preoperative processes and outcomes after implementation of a hospitalist-run preoperative clinic. J Hosp Med. 2012 Sep 7. doi:10.1002/jhm.1968.

Delirium after Cardiac Surgery Associated with Prolonged Cognitive Impairment

Clinical question: Is postoperative delirium associated with decreased cognitive function in the first year after cardiac surgery?

Background: In general populations, delirium has been associated with long-term decline in cognitive ability. Delirium and cognitive dysfunction are both common following cardiac surgery, but the effects of postoperative delirium on the trajectory of cognitive function over time is unclear.

Study design: Prospective cohort study.

Setting: Two academic medical centers and a Veterans Administration hospital.

Synopsis: Two hundred twenty-five patients aged 60 or older who were scheduled to undergo coronary artery bypass grafting or valve replacement surgery were included. Patients underwent preoperative assessment cognitive function with the use of the Mini-Mental State Examination (MMSE). Starting on postoperative Day 2, patients underwent daily assessment for delirium. After discharge, cognitive function was reassessed at months one, six, and 12.

Postoperative delirium occurred in 103 patients (46%). Patients with delirium were older, had higher comorbidity scores, and had lower MMSE scores at baseline. Among the overall study population, adjusted MMSE scores dropped 4.6 points from baseline to postoperative Day 2, then were observed to increase by approximately one point per day during postoperative days 3 to 5 with minimal change thereafter. Patients with delirium had greater decrease in cognitive function in the immediate postoperative period compared to patients without delirium (7.7 points vs. 2.1, P<0.001).

Patients without delirium returned to their baseline cognitive ability by one month postoperatively, while patients who had delirium were still making gains up to six months post-operatively, never returning to baseline level of function by one year. Unmeasured confounders and uncertain sensitivity of the MMSE to detect mild cognitive impairment might limit these findings.

Bottom line: Cognitive function decreases in the immediate postoperative period following cardiac surgery. Compared to patients without delirium, patients with delirium experience more dramatic and prolonged cognitive impairment postoperatively, without returning to their preoperative level of cognitive function at one year.

Citation: Saczynski JS, Marcantonio ER, Quach L, et al. Cognitive trajectories after postoperative delirium. New Engl J Med. 2012;367:30-39.

Benefits of Resuming Anticoagulation after GI Bleed Outweigh Risks for Most Patients

Clinical question: In warfarin-treated patients who have experienced gastrointestinal (GI) bleeding, what are the patterns of restarting warfarin therapy and the incidence of thrombosis, recurrent GI bleed, and death in the 90 days following index bleed?

Background: In warfarin-treated patients who experience GI bleeding, warfarin is often temporarily held or permanently discontinued, placing patients at increased risk for developing thromboembolism. Little is known about the risks, benefits, and timing of restarting warfarin in this patient population.

Study design: Retrospective cohort study.

Setting: Kaiser Permanente Colorado.

Synopsis: Using clinical and administrative databases, 442 patients who presented with GI bleeding while receiving warfarin therapy were identified. Patients were grouped by whether they resumed warfarin (n=260, including 41 patients in whom anticoagulation was never interrupted), or did not resume warfarin therapy (n=182) in the 90 days following index GI bleed. Patients with prosthetic heart valves or GI bleeding localized to the rectum/anus were more commonly restarted on warfarin, whereas older patients and those in whom the source of bleeding was not identified were less likely to be restarted on warfarin therapy.

Restarting warfarin therapy after index GI bleed was associated with lower risk of thrombosis (HR 0.05, 95% CI 0.01-0.58) and death from any cause (HR 0.31, 95% CI 0.15-0.62), and it was not associated with a significant increase in risk for recurrent GI bleed (HR 1.32, 95% CI 0.50-3.57).

The authors concluded that for many patients who experience a warfarin-associated GI bleed, the benefits of restarting warfarin therapy outweigh the risks. No conclusions were made regarding the optimal timing of resuming therapy. Limitations included the use of administrative data and inability to determine the potential influence of aspirin use on outcomes.

Bottom line: Resuming warfarin in the 90 days following a warfarin-associated GI bleed is associated with decreased risk of thrombosis and death without increased risk for recurrent GI bleed.

Citation: Witt DM, Delate T, Garcia DA, et al. Risk of thromboembolism, recurrent hemorrhage, and death after warfarin therapy interruption for gastrointestinal tract bleeding. Arch Intern Med. 2012 Sep 12. doi:10.1001/archinternmed.2012.4261.

Preoperative Hyponatremia Associated with Increased Risk for Perioperative Complications and Mortality

Clinical question: Is preoperative hyponatremia an indicator of perioperative morbidity and mortality?

Background: Hyponatremia is a common diagnosis in the hospital setting and is associated with adverse outcomes, even in mild cases. However, it is unclear if this association exists in surgical patients when detected preoperatively.

Study design: Retrospective cohort study.

Setting: Academic and community hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP).

Synopsis: A total of 75,423 adult patients with hyponatremia (sodium <135 mEq/L) who were undergoing major surgery were compared to 888,840 patients with normal preoperative sodium levels over a six-year period. The primary outcome was 30-day mortality. Secondary outcomes included postoperative major coronary events, stroke, wound infection, pneumonia, and length of stay (LOS).

Compared to patients with normal sodium levels, those with preoperative hyponatremia had higher rates of perioperative mortality (5.2% vs. 1.3%; adjusted odds ratio 1.44, 95% CI 1.38-1.50), with increased risk that correlated with increasing severity of hyponatremia. Association with postoperative mortality was particularly strong among hyponatremic patients with ASA scores of 1 or 2 and those undergoing nonemergency surgery.

Patients with preoperative hyponatremia were also found to have increased risk for all postoperative complications evaluated, with the exception of stroke. Limitations included the potential for unmeasured confounders and not being able to account for the role of medications used perioperatively. Research is needed to determine whether correcting preoperative hyponatremia lessens the risk of mortality and other postoperative complications.

Bottom line: Among patients undergoing major surgery, preoperative hyponatremia is a predictor of postoperative 30-day mortality and morbidity.

Citation: Leung AA, McAlister FA, Rogers SO, et al. Preoperative hyponatremia and perioperative complications. Arch Intern Med. 2012;172:1-8.

Clinical question: How helpful is the “gut feeling” that clinicians might have that a child is more ill than they look?

Background: Timely recognition of serious infections in children is difficult but critical to improved outcomes. Numerous studies have examined clinical criteria and laboratory tests to distinguish viral infections from more serious bacterial infections but have demonstrated mixed results. Clinicians’ subjective impressions of patients continue to drive many care patterns, and the relevance of a gut feeling that something is wrong remains unclear.

Study design: Prospective observational study.

Setting: Primary-care clinics in Flanders, Belgium.

Synopsis: Nearly 4,000 children 0-16 years of age were evaluated after presentation for acute illness in primary-care settings. Clinical features, overall “clinical impression” (serious illness present or absent), and “gut feelings” (present, absent or unsure) that something was wrong were prospectively recorded. Serious infections were defined as hospital admissions for potential bacterial infections.

The presence of a gut feeling significantly increased the risk of serious illness (likelihood ratio 25.5, 95% confidence interval 7.9 to 82.0) and had a consistently higher specificity than clinical impression alone. The overall sensitivity of the gut feeling in this cohort was 61.9% with a specificity of 97.2%, while the positive predictive value was 10.8% and negative predictive value 99.8%. A history of convulsions and parental concerns were independently strongly associated with a positive gut feeling.

Similar to other clinical and laboratory evaluations designed to detect serious illness, the absence of a gut feeling might be the more useful finding from this study. Limitations of the data include an inability to further delve into what gives rise to a gut feeling in clinical practice as well as a moderate level of variance in the multivariate models. Additionally, only 21 children were ultimately admitted to the hospital, which, in conjunction with the subsequent power limitations, highlights the proverbial difficulty of finding that “needle in the haystack.”

Bottom line: The presence or absence of a gut feeling that something is wrong might be an important component of the history in acute childhood illness.

Citation: Van den Bruel A, Thompson M, Buntinx F, Mant D. Clinicians’ gut feeling about serious infections in children: observational study. BMJ. 2012;345:e6144.

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

Clinical question: How helpful is the “gut feeling” that clinicians might have that a child is more ill than they look?

Background: Timely recognition of serious infections in children is difficult but critical to improved outcomes. Numerous studies have examined clinical criteria and laboratory tests to distinguish viral infections from more serious bacterial infections but have demonstrated mixed results. Clinicians’ subjective impressions of patients continue to drive many care patterns, and the relevance of a gut feeling that something is wrong remains unclear.

Study design: Prospective observational study.

Setting: Primary-care clinics in Flanders, Belgium.

Synopsis: Nearly 4,000 children 0-16 years of age were evaluated after presentation for acute illness in primary-care settings. Clinical features, overall “clinical impression” (serious illness present or absent), and “gut feelings” (present, absent or unsure) that something was wrong were prospectively recorded. Serious infections were defined as hospital admissions for potential bacterial infections.

The presence of a gut feeling significantly increased the risk of serious illness (likelihood ratio 25.5, 95% confidence interval 7.9 to 82.0) and had a consistently higher specificity than clinical impression alone. The overall sensitivity of the gut feeling in this cohort was 61.9% with a specificity of 97.2%, while the positive predictive value was 10.8% and negative predictive value 99.8%. A history of convulsions and parental concerns were independently strongly associated with a positive gut feeling.

Similar to other clinical and laboratory evaluations designed to detect serious illness, the absence of a gut feeling might be the more useful finding from this study. Limitations of the data include an inability to further delve into what gives rise to a gut feeling in clinical practice as well as a moderate level of variance in the multivariate models. Additionally, only 21 children were ultimately admitted to the hospital, which, in conjunction with the subsequent power limitations, highlights the proverbial difficulty of finding that “needle in the haystack.”

Bottom line: The presence or absence of a gut feeling that something is wrong might be an important component of the history in acute childhood illness.

Citation: Van den Bruel A, Thompson M, Buntinx F, Mant D. Clinicians’ gut feeling about serious infections in children: observational study. BMJ. 2012;345:e6144.

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

Clinical question: How helpful is the “gut feeling” that clinicians might have that a child is more ill than they look?

Background: Timely recognition of serious infections in children is difficult but critical to improved outcomes. Numerous studies have examined clinical criteria and laboratory tests to distinguish viral infections from more serious bacterial infections but have demonstrated mixed results. Clinicians’ subjective impressions of patients continue to drive many care patterns, and the relevance of a gut feeling that something is wrong remains unclear.

Study design: Prospective observational study.

Setting: Primary-care clinics in Flanders, Belgium.

Synopsis: Nearly 4,000 children 0-16 years of age were evaluated after presentation for acute illness in primary-care settings. Clinical features, overall “clinical impression” (serious illness present or absent), and “gut feelings” (present, absent or unsure) that something was wrong were prospectively recorded. Serious infections were defined as hospital admissions for potential bacterial infections.

The presence of a gut feeling significantly increased the risk of serious illness (likelihood ratio 25.5, 95% confidence interval 7.9 to 82.0) and had a consistently higher specificity than clinical impression alone. The overall sensitivity of the gut feeling in this cohort was 61.9% with a specificity of 97.2%, while the positive predictive value was 10.8% and negative predictive value 99.8%. A history of convulsions and parental concerns were independently strongly associated with a positive gut feeling.

Similar to other clinical and laboratory evaluations designed to detect serious illness, the absence of a gut feeling might be the more useful finding from this study. Limitations of the data include an inability to further delve into what gives rise to a gut feeling in clinical practice as well as a moderate level of variance in the multivariate models. Additionally, only 21 children were ultimately admitted to the hospital, which, in conjunction with the subsequent power limitations, highlights the proverbial difficulty of finding that “needle in the haystack.”

Bottom line: The presence or absence of a gut feeling that something is wrong might be an important component of the history in acute childhood illness.

Citation: Van den Bruel A, Thompson M, Buntinx F, Mant D. Clinicians’ gut feeling about serious infections in children: observational study. BMJ. 2012;345:e6144.

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

Case

A generally healthy, 74-year-old man presents with sudden-onset abdominal pain due to acute pancreatitis. Computed tomography (CT) of his abdomen shows pancreatic inflammation and an incidental finding of a 4.5-cm abdominal aortic aneurysm. He had never had any imaging of his abdomen prior to this study and described no prior episodes of abdominal pain.

When should his abdominal aortic aneurysm be treated?

Overview

An abdominal aortic aneurysm (AAA) is an abnormal dilation of the abdominal aorta between the diaphragm and the aortic bifurcation of the iliac arteries. An AAA is usually defined as a dilatation with a diameter of >3 cm or 50% greater than the typical diameter. Most AAAs are located in the infrarenal aorta, proximal to the iliac bifurcation.

Population screening programs show a prevalence of AAA of 4% to 8% in men aged 65 to 80 years.¹ AAA prevalence is approximately six times greater in men than women, though the prevalence in women might be increasing.¹ AAA is most common in white men, with black men and those of Asian heritage having lower risk. A combination of genetic predisposition and environmental and physiologic factors lead to initiation and progression of AAAs; family history, male sex, advanced age, and history of smoking are major risk factors.

Mortality after AAA rupture is high. Approximately 62% of patients die prior to hospital arrival.² Of those who undergo emergent AAA surgery, 50% will die.¹

Aortic repair with a prosthetic vascular graft reduces morbidity and mortality from rupture, but the risks of repair are not trivial.²

Review of the Data

Risk of rupture. An AAA should be repaired when the risk of rupture outweighs the risks of surgical repair. Symptomatic aneurysms—such as those causing back or abdominal pain—have a higher risk of rupture than asymptomatic aneurysms. Most AAAs are asymptomatic and, in the absence of imaging, not identified until the time of rupture. Given the significant mortality associated with rupture, there is benefit to intervening on asymptomatic aneurysms before rupture.

The risk of AAA rupture has been studied in patients who either have been unfit for surgical repair or uninterested in intervention. Risk of rupture increases substantially with aneurysm size. Lederle et al estimated a two-year aneurysm rupture risk of 22.1% for AAA with a diameter of 5.0 to 5.9 cm, 18.9% for 6.0 to 6.9 cm, and 43.4% for a diameter ≥7.0 cm.³ In another study of 476 patients, the average risks of rupture in male and female patients with an AAA of 5.0 to 5.9 cm were 1.0% and 3.9% per year, respectively. For male and female patients with ≥6.0 cm AAAs, risks of rupture were 14.1% and 22.3% per year.⁴ Women with AAA have been found to have a higher risk of rupture in all studies in which female patients were included.

Because rupture risk increases with size, predicting the rate of growth is clinically important. Powell et al conducted a systematic review of growth rates of small AAAs.⁵ In 15 studies that examined 7,630 patients, the growth rate for a 3.5-cm aneurysm was estimated at 1.9 mm/year and for a 4.5-cm aneurysm was 3.5 mm/year. Given an exponentially increasing aneurysm diameter, this suggests an elapsed time of 6.2 years for a 3.5-cm aneurysm to grow to 5.5 cm, and 2.3 years for a 4.5-cm AAA to grow to 5.5 cm. This prediction does not account for individual variability in growth rate. Some AAAs grow quickly, others erratically, and others not at all. This growth variability is influenced by individual characteristics including cigarette smoking, sex, age, and other factors.

Medical prevention of progression and rupture. Studies have assessed whether modification of risk factors can delay progression of growth of AAAs. In a small aneurysm trial in the United Kingdom, self-reported smoking status was associated with an incrementally increased growth rate of 0.4 mm per year.⁵ Each year of smoking increases the relative risk of AAA by 4%, and continued smoking leads to more rapid AAA expansion.6 There is no clear relationship between cholesterol levels and AAA expansion rate. Observational studies suggest that aneurysm expansion decreases with statin use, but there is not sufficient evidence to recommend statin therapy for AAA alone.⁶

Many patients with AAA, however, are candidates for statins because of concomitant coronary artery or peripheral vascular disease. Small, randomized controlled trials have shown that macrolides and tetracycline antibiotics might inhibit AAA growth, but prescribing them for this purpose is not currently the standard of care.⁷ Elevated mean blood pressure has been associated with rupture, but there is not good evidence showing delay of progression with treatment of hypertension.⁶ Early observational studies suggested that beta-blocker use would decrease AAA progression, but further evidence has not supported their benefit in slowing progression of size.⁸ Likewise, use of angiotensin-converting enzyme inhibitors has also shown no growth inhibition.⁷ An ongoing Cochrane review is evaluating evidence for these medical treatments of AAA.⁹

Surgical prevention of rupture. There are two surgical methods of AAA repair: open repair and endovascular aneurysm repair (EVAR). Both involve use of a prosthetic graft to prevent the aneurysm from enlarging. The EVAR procedure typically involves entry at the femoral artery, with use of catheters and guide wires to advance a graft to the desired location and anchor it in place. Because this utilizes an endovascular approach, regional rather than general anesthesia can be used.

Multiple investigators have evaluated for differences in outcomes between the two methods of surgical AAA repair. Studies have shown increased 30-day postoperative mortality with open repair, as well as significantly higher rates of postoperative cardiac, pulmonary, and renal complications. One randomized controlled study found 30-day operative mortality of 1.8% in the EVAR group and 4.3% in the open repair group.¹⁰ However, after a median six-year follow-up of patients after EVAR or open repair, there is no difference in total mortality or aneurysm-related mortality.¹⁰ Compared with open repair, the need for long-term surveillance and re-intervention post-EVAR is higher, with endoleak and graft migration the most common complications. This accounts for the loss of early survival advantage in post-EVAR patients. By two years post-operation, complication after repair with either technique is not statistically different. De Bruin et al found that six years after randomization for repair type, cumulative survival rates were 69.9% for patients after open repair and 68.9% with EVAR.¹¹

Studies also have focused on subgroups of patients with a higher operative risk and shorter life expectancy, such as the elderly.¹² A pooled analysis of 13,419 patients aged ≥80 years from six observational studies showed 8.6% immediate mortality after open repair and 2.3% after EVAR (risk difference 6.2%, 95% CI 5.4-7.0%).¹³ Pooled analysis of three longer-term studies showed similar overall survival at three years after EVAR and open repair.¹³ When EVAR is not available, open repair has acceptable short- and long-term survival in patients aged ≥80 years with an AAA at high risk of rupture.¹⁴

Screening. A Cochrane review evaluated the effect of ultrasound screening of asymptomatic AAA on mortality. In 127,891 men and 9,342 women aged 65 to 79, researchers found a significant decrease in mortality in men aged 65 to 79 who were screened (odds ratio 0.6, 95% CI 0.47-0.78) but no benefit to screening of women.15 The current U.S. Preventive Services Task Force (USPSTF) guidelines recommend one-time ultrasound-guided (USG) screening for AAA in men aged 65 to 75 who have any history of tobacco use. For men in this age group who have never smoked, the balance between benefits and harms of screening is too close for the USPSTF to make recommendations. Because of the lower prevalence in women, the USPSTF recommends against screening women for AAA.¹⁸

Timing of repair. Early repair of small AAAs (4 cm to 5.5 cm) has no long-term survival benefit compared to ultrasound surveillance without repair.^16,17 Therefore, AAAs <5.5 cm should be followed with regular ultrasound surveillance every six months, with referral to surgery if the diameter reaches 5.5 cm, or grows >1 cm a year. The size at which surgery should be performed might be lower in women, given that their risk of rupture is higher than men. A thoughtful discussion of individual risks should take place in every case, but in many patients, even the elderly, repair of a large asymptomatic AAA is indicated. ⁵

Back to the Case

Our patient should have repeat imaging of his AAA in six months and regular surveillance afterward to monitor for growth every six months. When the AAA is >5.5 cm or if it grows >1 cm a year, he should be evaluated for EVAR or open repair.

Bottom Line

The current USPSTF guidelines recommend one-time ultrasound-guided (USG) screening for AAA in men aged 65 to 75 with a history of smoking. If an AAA >3 cm is found, the patient should undergo regular USG screening every six months. The AAA should be repaired if >5.5 cm or symptomatic, via either an endoscopic or open approach.

Dr. Best is a hospitalist at University of Washington Medicine at Harborview and associate program director of the internal-medicine residency program at the University of Washington, Seattle. Dr. Carpenter is a fellow in the division of geriatrics at the University of California at San Franscisco.

References

1. Nordon IM, Hinchliffe RJ, Loftus IM, Thompson MM. Pathophysiology and epidemiology of abdominal aortic aneurysms. Nat Rev Cardiol. 2011;8, 92-102.
2. Ernst CB. Abdominal aortic aneurysm. N Engl J Med. 1993;328(16):1167-1172.
3. Lederle FA, Johnson GR, Wilson SE, et al. Rupture rate of large abdominal aortic aneurysms in patients refusing or unfit for elective repair. JAMA. 2002;287:2968-2972
4. Brown PM, Zelt DT, Sobolev B. The risk of rupture in untreated aneurysms: the impact of size, gender, and expansion rate. J Vasc Surg. 2003;37:280-284.
5. Powell JT, Sweeting MJ, Brown LC, Gotensparre SM, Fowkes FG, Thompson SG. Systematic review and meta-analysis of growth rates of small abdominal aortic aneurysms. British Journal of Surgery. 2011;98:609-618.
6. Brown LC, Powell JT. Risk factors for aneurysm rupture in patients kept under ultrasound surveillance. UK Small Aneurysm Trial Participants. Ann Surg. 1999;230(3):289-297.
7. Baxter BT, Terrin MC, Dalman RL. Medical management of small abdominal aortic aneurysms. Circulation. 2008;117:1883-1889.
8. The Propranolol Aneurysm Trial Investigators. Propranolol for small abdominal aortic aneurysms: results of a randomized trial. J Vasc Surg. 2002:35:72-79.
9. Ruhani G, Robertson L, Clarke M. Medical treatment for small abdominal aortic aneurysms. Cochrane Database for Systematic Reviews 2012. Sep 12;9:CD009536. doi: 10.1002/14651858.
10. The United Kingdom EVAR Trial Investigators. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med. 2010; 362:1863-1871.
11. De Bruin JL, Baas AF, Buth J, et al. Long-term outcome of open or endovascular repair of abdominal aortic aneurysm. N Engl J Med. 2010;362:1881-1889.
12. Jackson RS, Chang DC, Freischlag JA. Comparison of long-term survival after open vs. endovascular repair of intact abdominal aortic aneurysm among Medicare beneficiaries. JAMA. 2012;307(15):1621-1628.
13. Biancari F, Catania A, D’Andrea V. Elective endovascular vs. open repair of abdominal aortic aneurysm in patients aged 80 years and older: systematic review and meta-analysis. Eur J Vasc Endovasc Surg. 2011;42:571-576.
14. Schermerhorn ML, O’Malley AJ, Jhaveri A, Cotterill P, Pomposelli F, Landon BE. Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population. N Engl J Med. 2008;358:464-474.
15. Cosford PA, Leng GC, Tomas J. Screening for abdominal aortic aneurysm. Cochrane Database for Systematic Reviews 2007, Issue 2. Art. No.: CD002945. DOI: 10.1002/14651858.CD002945.pub2.
16. Filardo G, Powell JT, Martinez MA, Ballard DJ. Surgery for small asymptomatic abdominal aortic aneurysms. Cochrane Database for Systematic Reviews 2012, Issue 3. Art. No.:CD001835. DOI: 10.1002/14651858.CD001835.pub3.
17. The UK Small Aneurysm Trial Participants. Final 12-year follow-up of surgery versus surveillance in the UK small aneurysm trial. Brit J Surg. 2007;94:702-708.
18. U.S. Preventive Services Task Force. Screening for Abdominal Aortic Aneurysm: Recommendation Statement. AHRQ Publication No. 05-0569-A, February 2005.

Case

A generally healthy, 74-year-old man presents with sudden-onset abdominal pain due to acute pancreatitis. Computed tomography (CT) of his abdomen shows pancreatic inflammation and an incidental finding of a 4.5-cm abdominal aortic aneurysm. He had never had any imaging of his abdomen prior to this study and described no prior episodes of abdominal pain.

When should his abdominal aortic aneurysm be treated?

Overview

An abdominal aortic aneurysm (AAA) is an abnormal dilation of the abdominal aorta between the diaphragm and the aortic bifurcation of the iliac arteries. An AAA is usually defined as a dilatation with a diameter of >3 cm or 50% greater than the typical diameter. Most AAAs are located in the infrarenal aorta, proximal to the iliac bifurcation.

Population screening programs show a prevalence of AAA of 4% to 8% in men aged 65 to 80 years.¹ AAA prevalence is approximately six times greater in men than women, though the prevalence in women might be increasing.¹ AAA is most common in white men, with black men and those of Asian heritage having lower risk. A combination of genetic predisposition and environmental and physiologic factors lead to initiation and progression of AAAs; family history, male sex, advanced age, and history of smoking are major risk factors.

Mortality after AAA rupture is high. Approximately 62% of patients die prior to hospital arrival.² Of those who undergo emergent AAA surgery, 50% will die.¹

Aortic repair with a prosthetic vascular graft reduces morbidity and mortality from rupture, but the risks of repair are not trivial.²

Review of the Data

Risk of rupture. An AAA should be repaired when the risk of rupture outweighs the risks of surgical repair. Symptomatic aneurysms—such as those causing back or abdominal pain—have a higher risk of rupture than asymptomatic aneurysms. Most AAAs are asymptomatic and, in the absence of imaging, not identified until the time of rupture. Given the significant mortality associated with rupture, there is benefit to intervening on asymptomatic aneurysms before rupture.

The risk of AAA rupture has been studied in patients who either have been unfit for surgical repair or uninterested in intervention. Risk of rupture increases substantially with aneurysm size. Lederle et al estimated a two-year aneurysm rupture risk of 22.1% for AAA with a diameter of 5.0 to 5.9 cm, 18.9% for 6.0 to 6.9 cm, and 43.4% for a diameter ≥7.0 cm.³ In another study of 476 patients, the average risks of rupture in male and female patients with an AAA of 5.0 to 5.9 cm were 1.0% and 3.9% per year, respectively. For male and female patients with ≥6.0 cm AAAs, risks of rupture were 14.1% and 22.3% per year.⁴ Women with AAA have been found to have a higher risk of rupture in all studies in which female patients were included.

Because rupture risk increases with size, predicting the rate of growth is clinically important. Powell et al conducted a systematic review of growth rates of small AAAs.⁵ In 15 studies that examined 7,630 patients, the growth rate for a 3.5-cm aneurysm was estimated at 1.9 mm/year and for a 4.5-cm aneurysm was 3.5 mm/year. Given an exponentially increasing aneurysm diameter, this suggests an elapsed time of 6.2 years for a 3.5-cm aneurysm to grow to 5.5 cm, and 2.3 years for a 4.5-cm AAA to grow to 5.5 cm. This prediction does not account for individual variability in growth rate. Some AAAs grow quickly, others erratically, and others not at all. This growth variability is influenced by individual characteristics including cigarette smoking, sex, age, and other factors.

Medical prevention of progression and rupture. Studies have assessed whether modification of risk factors can delay progression of growth of AAAs. In a small aneurysm trial in the United Kingdom, self-reported smoking status was associated with an incrementally increased growth rate of 0.4 mm per year.⁵ Each year of smoking increases the relative risk of AAA by 4%, and continued smoking leads to more rapid AAA expansion.6 There is no clear relationship between cholesterol levels and AAA expansion rate. Observational studies suggest that aneurysm expansion decreases with statin use, but there is not sufficient evidence to recommend statin therapy for AAA alone.⁶

Many patients with AAA, however, are candidates for statins because of concomitant coronary artery or peripheral vascular disease. Small, randomized controlled trials have shown that macrolides and tetracycline antibiotics might inhibit AAA growth, but prescribing them for this purpose is not currently the standard of care.⁷ Elevated mean blood pressure has been associated with rupture, but there is not good evidence showing delay of progression with treatment of hypertension.⁶ Early observational studies suggested that beta-blocker use would decrease AAA progression, but further evidence has not supported their benefit in slowing progression of size.⁸ Likewise, use of angiotensin-converting enzyme inhibitors has also shown no growth inhibition.⁷ An ongoing Cochrane review is evaluating evidence for these medical treatments of AAA.⁹

Surgical prevention of rupture. There are two surgical methods of AAA repair: open repair and endovascular aneurysm repair (EVAR). Both involve use of a prosthetic graft to prevent the aneurysm from enlarging. The EVAR procedure typically involves entry at the femoral artery, with use of catheters and guide wires to advance a graft to the desired location and anchor it in place. Because this utilizes an endovascular approach, regional rather than general anesthesia can be used.

Multiple investigators have evaluated for differences in outcomes between the two methods of surgical AAA repair. Studies have shown increased 30-day postoperative mortality with open repair, as well as significantly higher rates of postoperative cardiac, pulmonary, and renal complications. One randomized controlled study found 30-day operative mortality of 1.8% in the EVAR group and 4.3% in the open repair group.¹⁰ However, after a median six-year follow-up of patients after EVAR or open repair, there is no difference in total mortality or aneurysm-related mortality.¹⁰ Compared with open repair, the need for long-term surveillance and re-intervention post-EVAR is higher, with endoleak and graft migration the most common complications. This accounts for the loss of early survival advantage in post-EVAR patients. By two years post-operation, complication after repair with either technique is not statistically different. De Bruin et al found that six years after randomization for repair type, cumulative survival rates were 69.9% for patients after open repair and 68.9% with EVAR.¹¹

Studies also have focused on subgroups of patients with a higher operative risk and shorter life expectancy, such as the elderly.¹² A pooled analysis of 13,419 patients aged ≥80 years from six observational studies showed 8.6% immediate mortality after open repair and 2.3% after EVAR (risk difference 6.2%, 95% CI 5.4-7.0%).¹³ Pooled analysis of three longer-term studies showed similar overall survival at three years after EVAR and open repair.¹³ When EVAR is not available, open repair has acceptable short- and long-term survival in patients aged ≥80 years with an AAA at high risk of rupture.¹⁴

Screening. A Cochrane review evaluated the effect of ultrasound screening of asymptomatic AAA on mortality. In 127,891 men and 9,342 women aged 65 to 79, researchers found a significant decrease in mortality in men aged 65 to 79 who were screened (odds ratio 0.6, 95% CI 0.47-0.78) but no benefit to screening of women.15 The current U.S. Preventive Services Task Force (USPSTF) guidelines recommend one-time ultrasound-guided (USG) screening for AAA in men aged 65 to 75 who have any history of tobacco use. For men in this age group who have never smoked, the balance between benefits and harms of screening is too close for the USPSTF to make recommendations. Because of the lower prevalence in women, the USPSTF recommends against screening women for AAA.¹⁸

Timing of repair. Early repair of small AAAs (4 cm to 5.5 cm) has no long-term survival benefit compared to ultrasound surveillance without repair.^16,17 Therefore, AAAs <5.5 cm should be followed with regular ultrasound surveillance every six months, with referral to surgery if the diameter reaches 5.5 cm, or grows >1 cm a year. The size at which surgery should be performed might be lower in women, given that their risk of rupture is higher than men. A thoughtful discussion of individual risks should take place in every case, but in many patients, even the elderly, repair of a large asymptomatic AAA is indicated. ⁵

Back to the Case

Our patient should have repeat imaging of his AAA in six months and regular surveillance afterward to monitor for growth every six months. When the AAA is >5.5 cm or if it grows >1 cm a year, he should be evaluated for EVAR or open repair.

Bottom Line

The current USPSTF guidelines recommend one-time ultrasound-guided (USG) screening for AAA in men aged 65 to 75 with a history of smoking. If an AAA >3 cm is found, the patient should undergo regular USG screening every six months. The AAA should be repaired if >5.5 cm or symptomatic, via either an endoscopic or open approach.

Dr. Best is a hospitalist at University of Washington Medicine at Harborview and associate program director of the internal-medicine residency program at the University of Washington, Seattle. Dr. Carpenter is a fellow in the division of geriatrics at the University of California at San Franscisco.

References

1. Nordon IM, Hinchliffe RJ, Loftus IM, Thompson MM. Pathophysiology and epidemiology of abdominal aortic aneurysms. Nat Rev Cardiol. 2011;8, 92-102.
2. Ernst CB. Abdominal aortic aneurysm. N Engl J Med. 1993;328(16):1167-1172.
3. Lederle FA, Johnson GR, Wilson SE, et al. Rupture rate of large abdominal aortic aneurysms in patients refusing or unfit for elective repair. JAMA. 2002;287:2968-2972
4. Brown PM, Zelt DT, Sobolev B. The risk of rupture in untreated aneurysms: the impact of size, gender, and expansion rate. J Vasc Surg. 2003;37:280-284.
5. Powell JT, Sweeting MJ, Brown LC, Gotensparre SM, Fowkes FG, Thompson SG. Systematic review and meta-analysis of growth rates of small abdominal aortic aneurysms. British Journal of Surgery. 2011;98:609-618.
6. Brown LC, Powell JT. Risk factors for aneurysm rupture in patients kept under ultrasound surveillance. UK Small Aneurysm Trial Participants. Ann Surg. 1999;230(3):289-297.
7. Baxter BT, Terrin MC, Dalman RL. Medical management of small abdominal aortic aneurysms. Circulation. 2008;117:1883-1889.
8. The Propranolol Aneurysm Trial Investigators. Propranolol for small abdominal aortic aneurysms: results of a randomized trial. J Vasc Surg. 2002:35:72-79.
9. Ruhani G, Robertson L, Clarke M. Medical treatment for small abdominal aortic aneurysms. Cochrane Database for Systematic Reviews 2012. Sep 12;9:CD009536. doi: 10.1002/14651858.
10. The United Kingdom EVAR Trial Investigators. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med. 2010; 362:1863-1871.
11. De Bruin JL, Baas AF, Buth J, et al. Long-term outcome of open or endovascular repair of abdominal aortic aneurysm. N Engl J Med. 2010;362:1881-1889.
12. Jackson RS, Chang DC, Freischlag JA. Comparison of long-term survival after open vs. endovascular repair of intact abdominal aortic aneurysm among Medicare beneficiaries. JAMA. 2012;307(15):1621-1628.
13. Biancari F, Catania A, D’Andrea V. Elective endovascular vs. open repair of abdominal aortic aneurysm in patients aged 80 years and older: systematic review and meta-analysis. Eur J Vasc Endovasc Surg. 2011;42:571-576.
14. Schermerhorn ML, O’Malley AJ, Jhaveri A, Cotterill P, Pomposelli F, Landon BE. Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population. N Engl J Med. 2008;358:464-474.
15. Cosford PA, Leng GC, Tomas J. Screening for abdominal aortic aneurysm. Cochrane Database for Systematic Reviews 2007, Issue 2. Art. No.: CD002945. DOI: 10.1002/14651858.CD002945.pub2.
16. Filardo G, Powell JT, Martinez MA, Ballard DJ. Surgery for small asymptomatic abdominal aortic aneurysms. Cochrane Database for Systematic Reviews 2012, Issue 3. Art. No.:CD001835. DOI: 10.1002/14651858.CD001835.pub3.
17. The UK Small Aneurysm Trial Participants. Final 12-year follow-up of surgery versus surveillance in the UK small aneurysm trial. Brit J Surg. 2007;94:702-708.
18. U.S. Preventive Services Task Force. Screening for Abdominal Aortic Aneurysm: Recommendation Statement. AHRQ Publication No. 05-0569-A, February 2005.

Case

A generally healthy, 74-year-old man presents with sudden-onset abdominal pain due to acute pancreatitis. Computed tomography (CT) of his abdomen shows pancreatic inflammation and an incidental finding of a 4.5-cm abdominal aortic aneurysm. He had never had any imaging of his abdomen prior to this study and described no prior episodes of abdominal pain.

When should his abdominal aortic aneurysm be treated?

Overview

An abdominal aortic aneurysm (AAA) is an abnormal dilation of the abdominal aorta between the diaphragm and the aortic bifurcation of the iliac arteries. An AAA is usually defined as a dilatation with a diameter of >3 cm or 50% greater than the typical diameter. Most AAAs are located in the infrarenal aorta, proximal to the iliac bifurcation.

Population screening programs show a prevalence of AAA of 4% to 8% in men aged 65 to 80 years.¹ AAA prevalence is approximately six times greater in men than women, though the prevalence in women might be increasing.¹ AAA is most common in white men, with black men and those of Asian heritage having lower risk. A combination of genetic predisposition and environmental and physiologic factors lead to initiation and progression of AAAs; family history, male sex, advanced age, and history of smoking are major risk factors.

Mortality after AAA rupture is high. Approximately 62% of patients die prior to hospital arrival.² Of those who undergo emergent AAA surgery, 50% will die.¹

Aortic repair with a prosthetic vascular graft reduces morbidity and mortality from rupture, but the risks of repair are not trivial.²

Review of the Data

Risk of rupture. An AAA should be repaired when the risk of rupture outweighs the risks of surgical repair. Symptomatic aneurysms—such as those causing back or abdominal pain—have a higher risk of rupture than asymptomatic aneurysms. Most AAAs are asymptomatic and, in the absence of imaging, not identified until the time of rupture. Given the significant mortality associated with rupture, there is benefit to intervening on asymptomatic aneurysms before rupture.

The risk of AAA rupture has been studied in patients who either have been unfit for surgical repair or uninterested in intervention. Risk of rupture increases substantially with aneurysm size. Lederle et al estimated a two-year aneurysm rupture risk of 22.1% for AAA with a diameter of 5.0 to 5.9 cm, 18.9% for 6.0 to 6.9 cm, and 43.4% for a diameter ≥7.0 cm.³ In another study of 476 patients, the average risks of rupture in male and female patients with an AAA of 5.0 to 5.9 cm were 1.0% and 3.9% per year, respectively. For male and female patients with ≥6.0 cm AAAs, risks of rupture were 14.1% and 22.3% per year.⁴ Women with AAA have been found to have a higher risk of rupture in all studies in which female patients were included.

Because rupture risk increases with size, predicting the rate of growth is clinically important. Powell et al conducted a systematic review of growth rates of small AAAs.⁵ In 15 studies that examined 7,630 patients, the growth rate for a 3.5-cm aneurysm was estimated at 1.9 mm/year and for a 4.5-cm aneurysm was 3.5 mm/year. Given an exponentially increasing aneurysm diameter, this suggests an elapsed time of 6.2 years for a 3.5-cm aneurysm to grow to 5.5 cm, and 2.3 years for a 4.5-cm AAA to grow to 5.5 cm. This prediction does not account for individual variability in growth rate. Some AAAs grow quickly, others erratically, and others not at all. This growth variability is influenced by individual characteristics including cigarette smoking, sex, age, and other factors.

Medical prevention of progression and rupture. Studies have assessed whether modification of risk factors can delay progression of growth of AAAs. In a small aneurysm trial in the United Kingdom, self-reported smoking status was associated with an incrementally increased growth rate of 0.4 mm per year.⁵ Each year of smoking increases the relative risk of AAA by 4%, and continued smoking leads to more rapid AAA expansion.6 There is no clear relationship between cholesterol levels and AAA expansion rate. Observational studies suggest that aneurysm expansion decreases with statin use, but there is not sufficient evidence to recommend statin therapy for AAA alone.⁶

Many patients with AAA, however, are candidates for statins because of concomitant coronary artery or peripheral vascular disease. Small, randomized controlled trials have shown that macrolides and tetracycline antibiotics might inhibit AAA growth, but prescribing them for this purpose is not currently the standard of care.⁷ Elevated mean blood pressure has been associated with rupture, but there is not good evidence showing delay of progression with treatment of hypertension.⁶ Early observational studies suggested that beta-blocker use would decrease AAA progression, but further evidence has not supported their benefit in slowing progression of size.⁸ Likewise, use of angiotensin-converting enzyme inhibitors has also shown no growth inhibition.⁷ An ongoing Cochrane review is evaluating evidence for these medical treatments of AAA.⁹

Surgical prevention of rupture. There are two surgical methods of AAA repair: open repair and endovascular aneurysm repair (EVAR). Both involve use of a prosthetic graft to prevent the aneurysm from enlarging. The EVAR procedure typically involves entry at the femoral artery, with use of catheters and guide wires to advance a graft to the desired location and anchor it in place. Because this utilizes an endovascular approach, regional rather than general anesthesia can be used.

Multiple investigators have evaluated for differences in outcomes between the two methods of surgical AAA repair. Studies have shown increased 30-day postoperative mortality with open repair, as well as significantly higher rates of postoperative cardiac, pulmonary, and renal complications. One randomized controlled study found 30-day operative mortality of 1.8% in the EVAR group and 4.3% in the open repair group.¹⁰ However, after a median six-year follow-up of patients after EVAR or open repair, there is no difference in total mortality or aneurysm-related mortality.¹⁰ Compared with open repair, the need for long-term surveillance and re-intervention post-EVAR is higher, with endoleak and graft migration the most common complications. This accounts for the loss of early survival advantage in post-EVAR patients. By two years post-operation, complication after repair with either technique is not statistically different. De Bruin et al found that six years after randomization for repair type, cumulative survival rates were 69.9% for patients after open repair and 68.9% with EVAR.¹¹

Studies also have focused on subgroups of patients with a higher operative risk and shorter life expectancy, such as the elderly.¹² A pooled analysis of 13,419 patients aged ≥80 years from six observational studies showed 8.6% immediate mortality after open repair and 2.3% after EVAR (risk difference 6.2%, 95% CI 5.4-7.0%).¹³ Pooled analysis of three longer-term studies showed similar overall survival at three years after EVAR and open repair.¹³ When EVAR is not available, open repair has acceptable short- and long-term survival in patients aged ≥80 years with an AAA at high risk of rupture.¹⁴

Screening. A Cochrane review evaluated the effect of ultrasound screening of asymptomatic AAA on mortality. In 127,891 men and 9,342 women aged 65 to 79, researchers found a significant decrease in mortality in men aged 65 to 79 who were screened (odds ratio 0.6, 95% CI 0.47-0.78) but no benefit to screening of women.15 The current U.S. Preventive Services Task Force (USPSTF) guidelines recommend one-time ultrasound-guided (USG) screening for AAA in men aged 65 to 75 who have any history of tobacco use. For men in this age group who have never smoked, the balance between benefits and harms of screening is too close for the USPSTF to make recommendations. Because of the lower prevalence in women, the USPSTF recommends against screening women for AAA.¹⁸

Timing of repair. Early repair of small AAAs (4 cm to 5.5 cm) has no long-term survival benefit compared to ultrasound surveillance without repair.^16,17 Therefore, AAAs <5.5 cm should be followed with regular ultrasound surveillance every six months, with referral to surgery if the diameter reaches 5.5 cm, or grows >1 cm a year. The size at which surgery should be performed might be lower in women, given that their risk of rupture is higher than men. A thoughtful discussion of individual risks should take place in every case, but in many patients, even the elderly, repair of a large asymptomatic AAA is indicated. ⁵

Back to the Case

Our patient should have repeat imaging of his AAA in six months and regular surveillance afterward to monitor for growth every six months. When the AAA is >5.5 cm or if it grows >1 cm a year, he should be evaluated for EVAR or open repair.

Bottom Line

The current USPSTF guidelines recommend one-time ultrasound-guided (USG) screening for AAA in men aged 65 to 75 with a history of smoking. If an AAA >3 cm is found, the patient should undergo regular USG screening every six months. The AAA should be repaired if >5.5 cm or symptomatic, via either an endoscopic or open approach.

Dr. Best is a hospitalist at University of Washington Medicine at Harborview and associate program director of the internal-medicine residency program at the University of Washington, Seattle. Dr. Carpenter is a fellow in the division of geriatrics at the University of California at San Franscisco.

References

1. Nordon IM, Hinchliffe RJ, Loftus IM, Thompson MM. Pathophysiology and epidemiology of abdominal aortic aneurysms. Nat Rev Cardiol. 2011;8, 92-102.
2. Ernst CB. Abdominal aortic aneurysm. N Engl J Med. 1993;328(16):1167-1172.
3. Lederle FA, Johnson GR, Wilson SE, et al. Rupture rate of large abdominal aortic aneurysms in patients refusing or unfit for elective repair. JAMA. 2002;287:2968-2972
4. Brown PM, Zelt DT, Sobolev B. The risk of rupture in untreated aneurysms: the impact of size, gender, and expansion rate. J Vasc Surg. 2003;37:280-284.
5. Powell JT, Sweeting MJ, Brown LC, Gotensparre SM, Fowkes FG, Thompson SG. Systematic review and meta-analysis of growth rates of small abdominal aortic aneurysms. British Journal of Surgery. 2011;98:609-618.
6. Brown LC, Powell JT. Risk factors for aneurysm rupture in patients kept under ultrasound surveillance. UK Small Aneurysm Trial Participants. Ann Surg. 1999;230(3):289-297.
7. Baxter BT, Terrin MC, Dalman RL. Medical management of small abdominal aortic aneurysms. Circulation. 2008;117:1883-1889.
8. The Propranolol Aneurysm Trial Investigators. Propranolol for small abdominal aortic aneurysms: results of a randomized trial. J Vasc Surg. 2002:35:72-79.
9. Ruhani G, Robertson L, Clarke M. Medical treatment for small abdominal aortic aneurysms. Cochrane Database for Systematic Reviews 2012. Sep 12;9:CD009536. doi: 10.1002/14651858.
10. The United Kingdom EVAR Trial Investigators. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med. 2010; 362:1863-1871.
11. De Bruin JL, Baas AF, Buth J, et al. Long-term outcome of open or endovascular repair of abdominal aortic aneurysm. N Engl J Med. 2010;362:1881-1889.
12. Jackson RS, Chang DC, Freischlag JA. Comparison of long-term survival after open vs. endovascular repair of intact abdominal aortic aneurysm among Medicare beneficiaries. JAMA. 2012;307(15):1621-1628.
13. Biancari F, Catania A, D’Andrea V. Elective endovascular vs. open repair of abdominal aortic aneurysm in patients aged 80 years and older: systematic review and meta-analysis. Eur J Vasc Endovasc Surg. 2011;42:571-576.
14. Schermerhorn ML, O’Malley AJ, Jhaveri A, Cotterill P, Pomposelli F, Landon BE. Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population. N Engl J Med. 2008;358:464-474.
15. Cosford PA, Leng GC, Tomas J. Screening for abdominal aortic aneurysm. Cochrane Database for Systematic Reviews 2007, Issue 2. Art. No.: CD002945. DOI: 10.1002/14651858.CD002945.pub2.
16. Filardo G, Powell JT, Martinez MA, Ballard DJ. Surgery for small asymptomatic abdominal aortic aneurysms. Cochrane Database for Systematic Reviews 2012, Issue 3. Art. No.:CD001835. DOI: 10.1002/14651858.CD001835.pub3.
17. The UK Small Aneurysm Trial Participants. Final 12-year follow-up of surgery versus surveillance in the UK small aneurysm trial. Brit J Surg. 2007;94:702-708.
18. U.S. Preventive Services Task Force. Screening for Abdominal Aortic Aneurysm: Recommendation Statement. AHRQ Publication No. 05-0569-A, February 2005.

Policymakers believe that publicly reporting healthcare performance results is essential to improving care delivery. In order to achieve a healthcare system that is consistently reliable, the Institute of Medicine (IOM) recently recommended that performance transparency be considered a foundational feature of healthcare systems that seek to constantly, systematically, and seamlessly improve.¹ The IOM has suggested strategies (see Table 1, right) for producing readily available information on safety, quality, prices and cost, and health outcomes. As these strategies are being deployed, it is essential that hospitalists consider the impact they will have on their personal practice, key stakeholders, and the patients that they serve.

Performance Data Sources

The accessibility of publicly reported healthcare performance information is increasing rapidly. Among HM practitioners, perhaps the most widely recognized data source is the Centers for Medicare & Medicaid Services’ (CMS) Hospital Compare website (www.hospitalcompare.hhs.gov). According to CMS, its performance information on more than 4,000 hospitals is intended to help patients make decisions about where to seek healthcare, as well as encourage hospitals to improve the quality of care they provide.

The information currently reported is extensive and comprehensive (see Table 2, right). Furthermore, CMS continually adds data as new performance measures are created and validated.

Beyond the federal government, private health insurance companies, consortiums of employer purchasers of healthcare (e.g. the Leapfrog Group), and community collaboratives (e.g. Minnesota Community Measurement in the state of Minnesota) are reporting care provider performance information.

In addition, consumer advocacy groups have entered the picture. Earlier this year, Consumer Reports magazine launched an initiative to rate the quality of hospitals (and cardiac surgery groups) through the publication of patient outcomes (central-line-associated bloodstream infections, surgical site infections, readmissions, complications, mortality), patient experience (communications about medications and discharge, and other markers of satisfaction), and hospital best practices (use of EHR, and the appropriate use of abdominal and chest CT scanning). Consumer Reports also provides a composite hospital safety score, and a 36-page technical manual explaining the strategy and methodology behind their ratings.

Public performance reporting is furthermore becoming big business for healthcare entrepreneurs. Castlight Health, with its $181 million in private capital backing, is viewed by some as the “Travelocity of healthcare.” Castlight calls its searchable databases “transparency portals” that allow consumers to understand, before they visit a care provider, what they will be paying and how the care provider ranks on quality and outcomes.

Finally, numerous unregulated Internet sites that employ methodologically questionable practices are reporting on healthcare performance. Many of these sources collect and publish subjective reports of care experiences, with little or no requirement that the reporter confirm the nature of the relationship that they have with the care provider.

Transparency and Key Stakeholders

The hospital that you work in expects you to know how it performs, and to help it improve in the areas over which you have influence. Hospitals monitor publicly reported data because their futures depend on strong performance. As of October 2012, hospital Medicare reimbursement is linked to publicly reported performance measures that were incorporated into CMS’ value-based purchasing (VBP) initiative. Furthermore, hospital market share will be increasingly dependent on performance transparency as consumers and patients utilize these data to make informed decisions about where to seek high-value healthcare.

Patients have a vested interest in knowing how their care providers perform. A recent study by PricewaterhouseCoopers reported that 72% of consumers ranked provider reputation and personal experience as the top drivers of provider choice.² Furthermore, employers and patients increasingly are demanding access to care affordability information—an interest driven in large part by the increasing popularity of consumer-directed health insurance plans (CDHPs). Under CDHPs, patients save money on premiums in exchange for higher deductibles that are typically paired with healthcare spending accounts. The intent is to increase consumer engagement and awareness of the cost of routine healthcare expenses while protecting against the cost of catastrophic events. It is estimated that 15% to 20% of people with employer-sponsored health insurance are in high-deductible plans, and many believe CDHPs will soon make up the majority of employer-provided coverage.

Patients interested in knowing how individual doctors perform will soon have increased access to this type of information as well. For example, CMS also produces a Physician Compare website (www.medicare.gov/find-a-doctor) that offers performance information on individual doctors. Currently, Physician Compare has little detailed information. Expect this to change, however, as Medicare moves forward with developing valid and reliable individual physician performance metrics for its Physician Value-Based Payment Modifier (VBPM) program (see “A New Measuring Stick,”).

Under VBPM, doctors will have payment modifiers assigned to their Medicare professional fee claims that will adjust payments based on the value of care that they have delivered historically. For example, it is possible in the future that physicians failing to prescribe ace inhibitors to heart failure patients will be paid less than physicians who universally provide evidence-based, best-practice heart failure care. The measurement period for the calculation of these modifiers begins this year, and hospitalists need to be aware that their performance after this time period might affect the amount of Medicare professional fee reimbursement they receive in the future.

Conclusions

Public performance reporting is a keystone healthcare reform strategy that will influence the behavior and practice patterns of hospitals and hospitalists. Hospitalists should regularly review publicly reported healthcare performance data, and commit to working collaboratively with colleagues to capitalize on improvement opportunities suggested by these data.

Dr. Frost is president of SHM.

References

1. Institute of Medicine. Best care at lower cost: The path to continuously learning health care in America. Institute of Medicine website. Available at: http://www.iom.edu/bestcare. Accessed Nov. 24, 2012.
2. PricewaterhouseCoopers’ Health Research Institute. Customer experience in healthcare: the moment of truth. PricewaterhouseCoopers website. Available at: http://www.pwc.com/es_MX/mx/publicaciones/archivo/2012-09-customer-experience-healthcare.pdf. Accessed Nov. 25, 2012.

Policymakers believe that publicly reporting healthcare performance results is essential to improving care delivery. In order to achieve a healthcare system that is consistently reliable, the Institute of Medicine (IOM) recently recommended that performance transparency be considered a foundational feature of healthcare systems that seek to constantly, systematically, and seamlessly improve.¹ The IOM has suggested strategies (see Table 1, right) for producing readily available information on safety, quality, prices and cost, and health outcomes. As these strategies are being deployed, it is essential that hospitalists consider the impact they will have on their personal practice, key stakeholders, and the patients that they serve.

Performance Data Sources

The accessibility of publicly reported healthcare performance information is increasing rapidly. Among HM practitioners, perhaps the most widely recognized data source is the Centers for Medicare & Medicaid Services’ (CMS) Hospital Compare website (www.hospitalcompare.hhs.gov). According to CMS, its performance information on more than 4,000 hospitals is intended to help patients make decisions about where to seek healthcare, as well as encourage hospitals to improve the quality of care they provide.

The information currently reported is extensive and comprehensive (see Table 2, right). Furthermore, CMS continually adds data as new performance measures are created and validated.

Beyond the federal government, private health insurance companies, consortiums of employer purchasers of healthcare (e.g. the Leapfrog Group), and community collaboratives (e.g. Minnesota Community Measurement in the state of Minnesota) are reporting care provider performance information.

In addition, consumer advocacy groups have entered the picture. Earlier this year, Consumer Reports magazine launched an initiative to rate the quality of hospitals (and cardiac surgery groups) through the publication of patient outcomes (central-line-associated bloodstream infections, surgical site infections, readmissions, complications, mortality), patient experience (communications about medications and discharge, and other markers of satisfaction), and hospital best practices (use of EHR, and the appropriate use of abdominal and chest CT scanning). Consumer Reports also provides a composite hospital safety score, and a 36-page technical manual explaining the strategy and methodology behind their ratings.

Public performance reporting is furthermore becoming big business for healthcare entrepreneurs. Castlight Health, with its $181 million in private capital backing, is viewed by some as the “Travelocity of healthcare.” Castlight calls its searchable databases “transparency portals” that allow consumers to understand, before they visit a care provider, what they will be paying and how the care provider ranks on quality and outcomes.

Finally, numerous unregulated Internet sites that employ methodologically questionable practices are reporting on healthcare performance. Many of these sources collect and publish subjective reports of care experiences, with little or no requirement that the reporter confirm the nature of the relationship that they have with the care provider.

Transparency and Key Stakeholders

The hospital that you work in expects you to know how it performs, and to help it improve in the areas over which you have influence. Hospitals monitor publicly reported data because their futures depend on strong performance. As of October 2012, hospital Medicare reimbursement is linked to publicly reported performance measures that were incorporated into CMS’ value-based purchasing (VBP) initiative. Furthermore, hospital market share will be increasingly dependent on performance transparency as consumers and patients utilize these data to make informed decisions about where to seek high-value healthcare.

Patients have a vested interest in knowing how their care providers perform. A recent study by PricewaterhouseCoopers reported that 72% of consumers ranked provider reputation and personal experience as the top drivers of provider choice.² Furthermore, employers and patients increasingly are demanding access to care affordability information—an interest driven in large part by the increasing popularity of consumer-directed health insurance plans (CDHPs). Under CDHPs, patients save money on premiums in exchange for higher deductibles that are typically paired with healthcare spending accounts. The intent is to increase consumer engagement and awareness of the cost of routine healthcare expenses while protecting against the cost of catastrophic events. It is estimated that 15% to 20% of people with employer-sponsored health insurance are in high-deductible plans, and many believe CDHPs will soon make up the majority of employer-provided coverage.

Patients interested in knowing how individual doctors perform will soon have increased access to this type of information as well. For example, CMS also produces a Physician Compare website (www.medicare.gov/find-a-doctor) that offers performance information on individual doctors. Currently, Physician Compare has little detailed information. Expect this to change, however, as Medicare moves forward with developing valid and reliable individual physician performance metrics for its Physician Value-Based Payment Modifier (VBPM) program (see “A New Measuring Stick,”).

Under VBPM, doctors will have payment modifiers assigned to their Medicare professional fee claims that will adjust payments based on the value of care that they have delivered historically. For example, it is possible in the future that physicians failing to prescribe ace inhibitors to heart failure patients will be paid less than physicians who universally provide evidence-based, best-practice heart failure care. The measurement period for the calculation of these modifiers begins this year, and hospitalists need to be aware that their performance after this time period might affect the amount of Medicare professional fee reimbursement they receive in the future.

Conclusions

Public performance reporting is a keystone healthcare reform strategy that will influence the behavior and practice patterns of hospitals and hospitalists. Hospitalists should regularly review publicly reported healthcare performance data, and commit to working collaboratively with colleagues to capitalize on improvement opportunities suggested by these data.

Dr. Frost is president of SHM.

References

1. Institute of Medicine. Best care at lower cost: The path to continuously learning health care in America. Institute of Medicine website. Available at: http://www.iom.edu/bestcare. Accessed Nov. 24, 2012.
2. PricewaterhouseCoopers’ Health Research Institute. Customer experience in healthcare: the moment of truth. PricewaterhouseCoopers website. Available at: http://www.pwc.com/es_MX/mx/publicaciones/archivo/2012-09-customer-experience-healthcare.pdf. Accessed Nov. 25, 2012.

Policymakers believe that publicly reporting healthcare performance results is essential to improving care delivery. In order to achieve a healthcare system that is consistently reliable, the Institute of Medicine (IOM) recently recommended that performance transparency be considered a foundational feature of healthcare systems that seek to constantly, systematically, and seamlessly improve.¹ The IOM has suggested strategies (see Table 1, right) for producing readily available information on safety, quality, prices and cost, and health outcomes. As these strategies are being deployed, it is essential that hospitalists consider the impact they will have on their personal practice, key stakeholders, and the patients that they serve.

Performance Data Sources

The accessibility of publicly reported healthcare performance information is increasing rapidly. Among HM practitioners, perhaps the most widely recognized data source is the Centers for Medicare & Medicaid Services’ (CMS) Hospital Compare website (www.hospitalcompare.hhs.gov). According to CMS, its performance information on more than 4,000 hospitals is intended to help patients make decisions about where to seek healthcare, as well as encourage hospitals to improve the quality of care they provide.

The information currently reported is extensive and comprehensive (see Table 2, right). Furthermore, CMS continually adds data as new performance measures are created and validated.

Beyond the federal government, private health insurance companies, consortiums of employer purchasers of healthcare (e.g. the Leapfrog Group), and community collaboratives (e.g. Minnesota Community Measurement in the state of Minnesota) are reporting care provider performance information.

In addition, consumer advocacy groups have entered the picture. Earlier this year, Consumer Reports magazine launched an initiative to rate the quality of hospitals (and cardiac surgery groups) through the publication of patient outcomes (central-line-associated bloodstream infections, surgical site infections, readmissions, complications, mortality), patient experience (communications about medications and discharge, and other markers of satisfaction), and hospital best practices (use of EHR, and the appropriate use of abdominal and chest CT scanning). Consumer Reports also provides a composite hospital safety score, and a 36-page technical manual explaining the strategy and methodology behind their ratings.

Public performance reporting is furthermore becoming big business for healthcare entrepreneurs. Castlight Health, with its $181 million in private capital backing, is viewed by some as the “Travelocity of healthcare.” Castlight calls its searchable databases “transparency portals” that allow consumers to understand, before they visit a care provider, what they will be paying and how the care provider ranks on quality and outcomes.

Finally, numerous unregulated Internet sites that employ methodologically questionable practices are reporting on healthcare performance. Many of these sources collect and publish subjective reports of care experiences, with little or no requirement that the reporter confirm the nature of the relationship that they have with the care provider.

Transparency and Key Stakeholders

The hospital that you work in expects you to know how it performs, and to help it improve in the areas over which you have influence. Hospitals monitor publicly reported data because their futures depend on strong performance. As of October 2012, hospital Medicare reimbursement is linked to publicly reported performance measures that were incorporated into CMS’ value-based purchasing (VBP) initiative. Furthermore, hospital market share will be increasingly dependent on performance transparency as consumers and patients utilize these data to make informed decisions about where to seek high-value healthcare.

Patients have a vested interest in knowing how their care providers perform. A recent study by PricewaterhouseCoopers reported that 72% of consumers ranked provider reputation and personal experience as the top drivers of provider choice.² Furthermore, employers and patients increasingly are demanding access to care affordability information—an interest driven in large part by the increasing popularity of consumer-directed health insurance plans (CDHPs). Under CDHPs, patients save money on premiums in exchange for higher deductibles that are typically paired with healthcare spending accounts. The intent is to increase consumer engagement and awareness of the cost of routine healthcare expenses while protecting against the cost of catastrophic events. It is estimated that 15% to 20% of people with employer-sponsored health insurance are in high-deductible plans, and many believe CDHPs will soon make up the majority of employer-provided coverage.

Patients interested in knowing how individual doctors perform will soon have increased access to this type of information as well. For example, CMS also produces a Physician Compare website (www.medicare.gov/find-a-doctor) that offers performance information on individual doctors. Currently, Physician Compare has little detailed information. Expect this to change, however, as Medicare moves forward with developing valid and reliable individual physician performance metrics for its Physician Value-Based Payment Modifier (VBPM) program (see “A New Measuring Stick,”).

Under VBPM, doctors will have payment modifiers assigned to their Medicare professional fee claims that will adjust payments based on the value of care that they have delivered historically. For example, it is possible in the future that physicians failing to prescribe ace inhibitors to heart failure patients will be paid less than physicians who universally provide evidence-based, best-practice heart failure care. The measurement period for the calculation of these modifiers begins this year, and hospitalists need to be aware that their performance after this time period might affect the amount of Medicare professional fee reimbursement they receive in the future.

Conclusions

Public performance reporting is a keystone healthcare reform strategy that will influence the behavior and practice patterns of hospitals and hospitalists. Hospitalists should regularly review publicly reported healthcare performance data, and commit to working collaboratively with colleagues to capitalize on improvement opportunities suggested by these data.

Dr. Frost is president of SHM.

References

1. Institute of Medicine. Best care at lower cost: The path to continuously learning health care in America. Institute of Medicine website. Available at: http://www.iom.edu/bestcare. Accessed Nov. 24, 2012.
2. PricewaterhouseCoopers’ Health Research Institute. Customer experience in healthcare: the moment of truth. PricewaterhouseCoopers website. Available at: http://www.pwc.com/es_MX/mx/publicaciones/archivo/2012-09-customer-experience-healthcare.pdf. Accessed Nov. 25, 2012.

As the Obama administration begins its second term, a great deal of attention is being paid to the advance of its healthcare reform agenda. Long overdue for reform is the sustainable growth rate (SGR) formula—an ill-fated attempt to provide predictable control for federal spending on Medicare by providing yearly updates (i.e. reductions) to Medicare’s physician reimbursement rates.

By adjusting the payment rates, the SGR was supposed to help control the cost of healthcare by linking it more closely with national growth and changes in the Medicare-eligible population. With each passing year, however, bipartisan consensus has grown stronger, the message being that a straight, fee-for-service system that is updated annually based on an expenditure target cannot substitute for fundamental delivery system reforms.

Genzink

Congress has acted to override the SGR’s implementation every year since 2003, with the latest round being a potential 27% gutting of Medicare reimbursement rates. This cycle is not only tiresome, but threatens a massive disruption to physician practices and to seniors’ access to the Medicare program.

“The SGR, while well-intentioned, is flawed, and Congress can provide its temporary override for only so long, while Medicare spending continues to grow,” says Ryan Genzink, PA-C, an SHM Public Policy Committee member and a physician assistant with IPC: The Hospitalist Co. in Grand Rapids, Mich.

Repeal and Reform

Although various SGR repeal bills have been introduced over the years, only one—the Medicare Physician Payment Innovation Act of 2012 (H.R. 5707)—supplements repeal with a realistic plan to move away from the current fee-for-service payment system (and its inherent inefficiencies) toward more cost-effective reimbursement models that are designed to promote quality and value through coordinated patient care.

This bipartisan bill, introduced by U.S. Reps. Allyson Schwartz (D-Pa.) and Joe Heck, DO (R-Nev.), would repeal the SGR, stabilize payments at current rates for 2013, replace scheduled reductions with positive and predictable updates from 2014 to 2017, and set an aggressive timetable for testing and evaluating new payment systems focused on improving quality and reducing costs (see “Specific Components of the Schwartz-Heck Proposal,” left). The bill is expected to be reintroduced in 2013.

“SHM agrees that it is time finally to eliminate the SGR and move away from the prevailing fee-for-service payment system, which rewards physicians for simply providing more services, to one that provides incentives to deliver higher-quality, cost-effective care to our nation’s seniors,” wrote SHM President Shaun Frost, MD, SFHM, in a letter of support last year to Schwartz and Heck, commending them for introducing their bill.

“By providing a menu of options for physician participation, including an alternative, value-driven fee-for-service system for physicians who are not able to participate in one of the new payment and delivery models, the legislation does not force all providers into a ‘one size fits all’ solution, allowing for broader support, innovation, and flexibility,” Dr. Frost said.

Advancing New Reimbursement Models

The Schwartz-Heck bill “gives a timeline for CMS to test and adopt different reimbursement models, which presents advantageous options for hospitalists,” says Lauren Doctoroff, MD, an SHM Public Policy Committee member, hospitalist, and medical director of the post-discharge clinic at Beth Israel Deaconess Medical Center in Boston. “Hospitalists already focus on providing higher-quality, lower-cost care to hospitalized patients in their daily practice. We build effective care transitions to the outpatient and extended care settings. Our strengths are perfectly aligned to help these new, value-based payment models succeed.”

Dr. Doctoroff

In fact, Dr. Doctoroff notes, Beth Israel is a participant in CMS’ Medicare Pioneer Accountable Care Organization project as well as Massachusetts Blue Cross Blue Shield’s Alternative Quality Contract, both of which use a risk-sharing global payment model in which the hospital and its physician network agree to provide for the healthcare needs of a defined population for a pre-arranged reimbursement amount.

“The global payment model is an attractive one for hospitalists because we play a key role in managing hospitalized patients efficiently and well, while also encouraging collaboration between inpatient and outpatient providers to avoid duplication of services,” Dr. Doctoroff says. “Some bundled payment models, which tie reimbursement to a defined episode of care, also could be advantageous for hospitalists, who coordinate the patient’s care throughout their entire healthcare episode, from inpatient diagnosis through post-discharge.”

Alternative Fee-for-Service System

For physicians who choose not to adopt one of the new reimbursement models, the bill directs CMS to offer an alternative fee-for-service system with incentives for improved quality and lower cost. This alternative would be available to physicians (including hospitalists) who participate in approved quality-reporting options, including the Physician Quality Reporting System (PQRS) or an approved Maintenance of Certification (MOC) program with quality registries. It also would apply to physicians who fall into the top 25% of CMS’ Value-Based Payment Modifier program (VBPM).

Boosting Primary Care

In addition to expediting the rollout of CMS-endorsed alternate payment models, the Schwartz bill recognizes the importance of primary care as the foundation of an effective healthcare delivery system and redresses its undervaluation with a 2.5% reimbursement update for physicians and other healthcare professionals for whom 60% of their Medicare physician fee schedule allowable charges are from a designated set of primary-care, preventive, and care-coordination codes.

“SHM specifically advocated for the inclusion of primary-care billing codes that hospitalists use,” Dr. Doctoroff says, “including hospital inpatient visits and observational services.”

“Of all the attempts to deal with the SGR over the past several years, Rep. Schwartz’s bill makes the most sense,” Genzink says. “While it doesn’t answer all of the healthcare system’s problems, it encapsulates many of the goals of reform—especially the shift from fee-for-service toward a payment system based on quality and outcomes. It recognizes that no one model will work for all physicians and offers the flexibility of multiple pathways. And it has bipartisan support, which seems to be a rarity these days.”

Chris Guadagnino is a freelance medical writer in Philadelphia.

As the Obama administration begins its second term, a great deal of attention is being paid to the advance of its healthcare reform agenda. Long overdue for reform is the sustainable growth rate (SGR) formula—an ill-fated attempt to provide predictable control for federal spending on Medicare by providing yearly updates (i.e. reductions) to Medicare’s physician reimbursement rates.

By adjusting the payment rates, the SGR was supposed to help control the cost of healthcare by linking it more closely with national growth and changes in the Medicare-eligible population. With each passing year, however, bipartisan consensus has grown stronger, the message being that a straight, fee-for-service system that is updated annually based on an expenditure target cannot substitute for fundamental delivery system reforms.

Genzink

Congress has acted to override the SGR’s implementation every year since 2003, with the latest round being a potential 27% gutting of Medicare reimbursement rates. This cycle is not only tiresome, but threatens a massive disruption to physician practices and to seniors’ access to the Medicare program.

“The SGR, while well-intentioned, is flawed, and Congress can provide its temporary override for only so long, while Medicare spending continues to grow,” says Ryan Genzink, PA-C, an SHM Public Policy Committee member and a physician assistant with IPC: The Hospitalist Co. in Grand Rapids, Mich.

Repeal and Reform

Although various SGR repeal bills have been introduced over the years, only one—the Medicare Physician Payment Innovation Act of 2012 (H.R. 5707)—supplements repeal with a realistic plan to move away from the current fee-for-service payment system (and its inherent inefficiencies) toward more cost-effective reimbursement models that are designed to promote quality and value through coordinated patient care.

This bipartisan bill, introduced by U.S. Reps. Allyson Schwartz (D-Pa.) and Joe Heck, DO (R-Nev.), would repeal the SGR, stabilize payments at current rates for 2013, replace scheduled reductions with positive and predictable updates from 2014 to 2017, and set an aggressive timetable for testing and evaluating new payment systems focused on improving quality and reducing costs (see “Specific Components of the Schwartz-Heck Proposal,” left). The bill is expected to be reintroduced in 2013.

“SHM agrees that it is time finally to eliminate the SGR and move away from the prevailing fee-for-service payment system, which rewards physicians for simply providing more services, to one that provides incentives to deliver higher-quality, cost-effective care to our nation’s seniors,” wrote SHM President Shaun Frost, MD, SFHM, in a letter of support last year to Schwartz and Heck, commending them for introducing their bill.

“By providing a menu of options for physician participation, including an alternative, value-driven fee-for-service system for physicians who are not able to participate in one of the new payment and delivery models, the legislation does not force all providers into a ‘one size fits all’ solution, allowing for broader support, innovation, and flexibility,” Dr. Frost said.

Advancing New Reimbursement Models

The Schwartz-Heck bill “gives a timeline for CMS to test and adopt different reimbursement models, which presents advantageous options for hospitalists,” says Lauren Doctoroff, MD, an SHM Public Policy Committee member, hospitalist, and medical director of the post-discharge clinic at Beth Israel Deaconess Medical Center in Boston. “Hospitalists already focus on providing higher-quality, lower-cost care to hospitalized patients in their daily practice. We build effective care transitions to the outpatient and extended care settings. Our strengths are perfectly aligned to help these new, value-based payment models succeed.”

Dr. Doctoroff

In fact, Dr. Doctoroff notes, Beth Israel is a participant in CMS’ Medicare Pioneer Accountable Care Organization project as well as Massachusetts Blue Cross Blue Shield’s Alternative Quality Contract, both of which use a risk-sharing global payment model in which the hospital and its physician network agree to provide for the healthcare needs of a defined population for a pre-arranged reimbursement amount.

“The global payment model is an attractive one for hospitalists because we play a key role in managing hospitalized patients efficiently and well, while also encouraging collaboration between inpatient and outpatient providers to avoid duplication of services,” Dr. Doctoroff says. “Some bundled payment models, which tie reimbursement to a defined episode of care, also could be advantageous for hospitalists, who coordinate the patient’s care throughout their entire healthcare episode, from inpatient diagnosis through post-discharge.”

Alternative Fee-for-Service System

For physicians who choose not to adopt one of the new reimbursement models, the bill directs CMS to offer an alternative fee-for-service system with incentives for improved quality and lower cost. This alternative would be available to physicians (including hospitalists) who participate in approved quality-reporting options, including the Physician Quality Reporting System (PQRS) or an approved Maintenance of Certification (MOC) program with quality registries. It also would apply to physicians who fall into the top 25% of CMS’ Value-Based Payment Modifier program (VBPM).

Boosting Primary Care

In addition to expediting the rollout of CMS-endorsed alternate payment models, the Schwartz bill recognizes the importance of primary care as the foundation of an effective healthcare delivery system and redresses its undervaluation with a 2.5% reimbursement update for physicians and other healthcare professionals for whom 60% of their Medicare physician fee schedule allowable charges are from a designated set of primary-care, preventive, and care-coordination codes.

“SHM specifically advocated for the inclusion of primary-care billing codes that hospitalists use,” Dr. Doctoroff says, “including hospital inpatient visits and observational services.”

“Of all the attempts to deal with the SGR over the past several years, Rep. Schwartz’s bill makes the most sense,” Genzink says. “While it doesn’t answer all of the healthcare system’s problems, it encapsulates many of the goals of reform—especially the shift from fee-for-service toward a payment system based on quality and outcomes. It recognizes that no one model will work for all physicians and offers the flexibility of multiple pathways. And it has bipartisan support, which seems to be a rarity these days.”

Chris Guadagnino is a freelance medical writer in Philadelphia.

As the Obama administration begins its second term, a great deal of attention is being paid to the advance of its healthcare reform agenda. Long overdue for reform is the sustainable growth rate (SGR) formula—an ill-fated attempt to provide predictable control for federal spending on Medicare by providing yearly updates (i.e. reductions) to Medicare’s physician reimbursement rates.

By adjusting the payment rates, the SGR was supposed to help control the cost of healthcare by linking it more closely with national growth and changes in the Medicare-eligible population. With each passing year, however, bipartisan consensus has grown stronger, the message being that a straight, fee-for-service system that is updated annually based on an expenditure target cannot substitute for fundamental delivery system reforms.

Genzink

Congress has acted to override the SGR’s implementation every year since 2003, with the latest round being a potential 27% gutting of Medicare reimbursement rates. This cycle is not only tiresome, but threatens a massive disruption to physician practices and to seniors’ access to the Medicare program.

“The SGR, while well-intentioned, is flawed, and Congress can provide its temporary override for only so long, while Medicare spending continues to grow,” says Ryan Genzink, PA-C, an SHM Public Policy Committee member and a physician assistant with IPC: The Hospitalist Co. in Grand Rapids, Mich.

Repeal and Reform

Although various SGR repeal bills have been introduced over the years, only one—the Medicare Physician Payment Innovation Act of 2012 (H.R. 5707)—supplements repeal with a realistic plan to move away from the current fee-for-service payment system (and its inherent inefficiencies) toward more cost-effective reimbursement models that are designed to promote quality and value through coordinated patient care.

This bipartisan bill, introduced by U.S. Reps. Allyson Schwartz (D-Pa.) and Joe Heck, DO (R-Nev.), would repeal the SGR, stabilize payments at current rates for 2013, replace scheduled reductions with positive and predictable updates from 2014 to 2017, and set an aggressive timetable for testing and evaluating new payment systems focused on improving quality and reducing costs (see “Specific Components of the Schwartz-Heck Proposal,” left). The bill is expected to be reintroduced in 2013.

“SHM agrees that it is time finally to eliminate the SGR and move away from the prevailing fee-for-service payment system, which rewards physicians for simply providing more services, to one that provides incentives to deliver higher-quality, cost-effective care to our nation’s seniors,” wrote SHM President Shaun Frost, MD, SFHM, in a letter of support last year to Schwartz and Heck, commending them for introducing their bill.

“By providing a menu of options for physician participation, including an alternative, value-driven fee-for-service system for physicians who are not able to participate in one of the new payment and delivery models, the legislation does not force all providers into a ‘one size fits all’ solution, allowing for broader support, innovation, and flexibility,” Dr. Frost said.

Advancing New Reimbursement Models

The Schwartz-Heck bill “gives a timeline for CMS to test and adopt different reimbursement models, which presents advantageous options for hospitalists,” says Lauren Doctoroff, MD, an SHM Public Policy Committee member, hospitalist, and medical director of the post-discharge clinic at Beth Israel Deaconess Medical Center in Boston. “Hospitalists already focus on providing higher-quality, lower-cost care to hospitalized patients in their daily practice. We build effective care transitions to the outpatient and extended care settings. Our strengths are perfectly aligned to help these new, value-based payment models succeed.”

Dr. Doctoroff

In fact, Dr. Doctoroff notes, Beth Israel is a participant in CMS’ Medicare Pioneer Accountable Care Organization project as well as Massachusetts Blue Cross Blue Shield’s Alternative Quality Contract, both of which use a risk-sharing global payment model in which the hospital and its physician network agree to provide for the healthcare needs of a defined population for a pre-arranged reimbursement amount.

“The global payment model is an attractive one for hospitalists because we play a key role in managing hospitalized patients efficiently and well, while also encouraging collaboration between inpatient and outpatient providers to avoid duplication of services,” Dr. Doctoroff says. “Some bundled payment models, which tie reimbursement to a defined episode of care, also could be advantageous for hospitalists, who coordinate the patient’s care throughout their entire healthcare episode, from inpatient diagnosis through post-discharge.”

Alternative Fee-for-Service System

For physicians who choose not to adopt one of the new reimbursement models, the bill directs CMS to offer an alternative fee-for-service system with incentives for improved quality and lower cost. This alternative would be available to physicians (including hospitalists) who participate in approved quality-reporting options, including the Physician Quality Reporting System (PQRS) or an approved Maintenance of Certification (MOC) program with quality registries. It also would apply to physicians who fall into the top 25% of CMS’ Value-Based Payment Modifier program (VBPM).

Boosting Primary Care

In addition to expediting the rollout of CMS-endorsed alternate payment models, the Schwartz bill recognizes the importance of primary care as the foundation of an effective healthcare delivery system and redresses its undervaluation with a 2.5% reimbursement update for physicians and other healthcare professionals for whom 60% of their Medicare physician fee schedule allowable charges are from a designated set of primary-care, preventive, and care-coordination codes.

“SHM specifically advocated for the inclusion of primary-care billing codes that hospitalists use,” Dr. Doctoroff says, “including hospital inpatient visits and observational services.”

“Of all the attempts to deal with the SGR over the past several years, Rep. Schwartz’s bill makes the most sense,” Genzink says. “While it doesn’t answer all of the healthcare system’s problems, it encapsulates many of the goals of reform—especially the shift from fee-for-service toward a payment system based on quality and outcomes. It recognizes that no one model will work for all physicians and offers the flexibility of multiple pathways. And it has bipartisan support, which seems to be a rarity these days.”

Chris Guadagnino is a freelance medical writer in Philadelphia.

It’s great to be a Tennessee Volunteer. I said, It’s great to be a Tennessee Volunteer!

The crowd, a sea of orange, packs into Neyland Stadium in Knoxville, Tenn., brimming with pride, dedicated to the team they call the Vols. Neyland Stadium, built in 1921, comfortably seats more than 100,000 brash fans on most fall weekends during the college football season. These die-hard fans pack the stadium regularly, hoping to catch a glimpse of victory.

Throughout the decades of Tennessee Volunteers football, numerous coaches have spent countless hours thinking about how to realize those victories. And they have also spent a lot time thinking about how to keep their players safe. Each coach has had different styles and tactics, but all had one thing in common: They were clearly invested in keeping their players safe. A safe player is a good player, one who can make the full season without injury. As such, before each practice and each game, the players don the gear required to play the safest game possible.

This gear is expensive, difficult to put on, difficult to keep on, makes them run slower, and makes them sweat heavier. When you think about it, it is a wonder that they wear it at all—unless you consider the fact that each precisely placed article takes them one step closer to surviving the game intact, and making it to the next victory. Just like any other type of protective equipment, football equipment has evolved over the course of time. The helmet, for example, is now custom-fit for each player with calipers, and then subsequent additions are applied to ensure durability, shock resistance, and comfort. Relatively new additions include eye shields (to protect the eyes and reduce glare) and even radio devices (to allow the coach to relay last-minute critical information to the quarterback). These helmets are all customized to the players’ position, to allow for the best balance between protection and visibility.

And the helmet is just the beginning. The remaining bare minimum amount of gear needed for standard player safety includes a mouthpiece, jaw pads, neck roll, shoulder pads, shock pads, rib pads, hip pads, knee pads, and cleats. All told, the weight of all this equipment is between 10 and 25 pounds and takes up to an hour to fully gear up. But nonetheless, it has become such a mainstay, of centralized importance to the game, that each team has a dedicated equipment manager. They are charged with providing, maintaining, and transporting the best gear for every member of the team. The equipment manager is a vital resource for the team and the sport.

Despite the extra weight and inconvenience that their gear can burden them with, you don’t see a single football player “skimp” on it. And it would certainly be obvious to all those around them if they ran onto the field without their helmet. Over the years, the football industry has not abandoned gear that they thought was less than perfect, too heavy, too bulky, or made the player perform with less agility. They just made the gear better, lighter, more comfortable, and more protective.

You Can Do This

In a similar fashion, hospital providers have become increasingly interested in keeping themselves—and the patient—safe. But have we come to consensus on who the coach and equipment managers should be, and what the essential elements of the gear should be? I would argue there are a number of coaches and equipment managers in the hospital setting whose mission is to keep their “players” safe. The players are both patients and providers, as generally a “safe provider” is one who makes and implements solid decisions, and who is housed within a safe, predictable, and highly-reliable system, is also one who can and will keep their patients safe.

We may not think of ourselves as such, but hospitalists can be extremely effective coaches and equipment managers. They can help create and maintain safe and effective gear for themselves and those patients and providers around them. They can be a mentor for displaying how vitally import this gear is and can work to improve it when it proves to be imperfect.

Although we don’t tend to think of these things as “safety gear,” these things do, in fact, keep us and our patients safe. Some of these include:

• Computerized physician order entry (CPOE) with decision support (or order sets without CPOE);
• Checklists;
• Procedural time-outs;
• Protocols;
• Medication dosing guidelines;
• Handheld devices (for quick lookup of medication doses, side effects, predictive scoring systems, medical calculators, etc.); and
• Gowns and gloves.

Additional “gear” for the patients can include:

• Arm bands for identification and medication scanning;
• Telemetry;
• Bed alarms;
• IV pumps with guard rails around dosing;
• Antibiotic impregnated central lines; and
• Early mobilization protocols.

The Next Level

To take the medical industry to the next level of safe reliability, we need all providers to accept and embrace the concept of “safety gear” for themselves and for their patients. We need to make it perfectly obvious when that gear is missing. It should invoke a reaction of ghastly fear when we witness anyone (provider, patient, or family) skimping on their gear: removing an armband for convenience, bypassing a smart pump, or skipping decision support in CPOE. And for the current gear that is imperfect, slows us down, beeps too often, or reduces our agility, the solution should include improving the gear, not ignoring it or discounting its importance.

So before you go to work today (every day?), think about what you need to keep yourself and your patients safe. And get your gear on.

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

It’s great to be a Tennessee Volunteer. I said, It’s great to be a Tennessee Volunteer!

The crowd, a sea of orange, packs into Neyland Stadium in Knoxville, Tenn., brimming with pride, dedicated to the team they call the Vols. Neyland Stadium, built in 1921, comfortably seats more than 100,000 brash fans on most fall weekends during the college football season. These die-hard fans pack the stadium regularly, hoping to catch a glimpse of victory.

Throughout the decades of Tennessee Volunteers football, numerous coaches have spent countless hours thinking about how to realize those victories. And they have also spent a lot time thinking about how to keep their players safe. Each coach has had different styles and tactics, but all had one thing in common: They were clearly invested in keeping their players safe. A safe player is a good player, one who can make the full season without injury. As such, before each practice and each game, the players don the gear required to play the safest game possible.

This gear is expensive, difficult to put on, difficult to keep on, makes them run slower, and makes them sweat heavier. When you think about it, it is a wonder that they wear it at all—unless you consider the fact that each precisely placed article takes them one step closer to surviving the game intact, and making it to the next victory. Just like any other type of protective equipment, football equipment has evolved over the course of time. The helmet, for example, is now custom-fit for each player with calipers, and then subsequent additions are applied to ensure durability, shock resistance, and comfort. Relatively new additions include eye shields (to protect the eyes and reduce glare) and even radio devices (to allow the coach to relay last-minute critical information to the quarterback). These helmets are all customized to the players’ position, to allow for the best balance between protection and visibility.

And the helmet is just the beginning. The remaining bare minimum amount of gear needed for standard player safety includes a mouthpiece, jaw pads, neck roll, shoulder pads, shock pads, rib pads, hip pads, knee pads, and cleats. All told, the weight of all this equipment is between 10 and 25 pounds and takes up to an hour to fully gear up. But nonetheless, it has become such a mainstay, of centralized importance to the game, that each team has a dedicated equipment manager. They are charged with providing, maintaining, and transporting the best gear for every member of the team. The equipment manager is a vital resource for the team and the sport.

Despite the extra weight and inconvenience that their gear can burden them with, you don’t see a single football player “skimp” on it. And it would certainly be obvious to all those around them if they ran onto the field without their helmet. Over the years, the football industry has not abandoned gear that they thought was less than perfect, too heavy, too bulky, or made the player perform with less agility. They just made the gear better, lighter, more comfortable, and more protective.

You Can Do This

In a similar fashion, hospital providers have become increasingly interested in keeping themselves—and the patient—safe. But have we come to consensus on who the coach and equipment managers should be, and what the essential elements of the gear should be? I would argue there are a number of coaches and equipment managers in the hospital setting whose mission is to keep their “players” safe. The players are both patients and providers, as generally a “safe provider” is one who makes and implements solid decisions, and who is housed within a safe, predictable, and highly-reliable system, is also one who can and will keep their patients safe.

We may not think of ourselves as such, but hospitalists can be extremely effective coaches and equipment managers. They can help create and maintain safe and effective gear for themselves and those patients and providers around them. They can be a mentor for displaying how vitally import this gear is and can work to improve it when it proves to be imperfect.

Although we don’t tend to think of these things as “safety gear,” these things do, in fact, keep us and our patients safe. Some of these include:

• Computerized physician order entry (CPOE) with decision support (or order sets without CPOE);
• Checklists;
• Procedural time-outs;
• Protocols;
• Medication dosing guidelines;
• Handheld devices (for quick lookup of medication doses, side effects, predictive scoring systems, medical calculators, etc.); and
• Gowns and gloves.

Additional “gear” for the patients can include:

• Arm bands for identification and medication scanning;
• Telemetry;
• Bed alarms;
• IV pumps with guard rails around dosing;
• Antibiotic impregnated central lines; and
• Early mobilization protocols.

The Next Level

To take the medical industry to the next level of safe reliability, we need all providers to accept and embrace the concept of “safety gear” for themselves and for their patients. We need to make it perfectly obvious when that gear is missing. It should invoke a reaction of ghastly fear when we witness anyone (provider, patient, or family) skimping on their gear: removing an armband for convenience, bypassing a smart pump, or skipping decision support in CPOE. And for the current gear that is imperfect, slows us down, beeps too often, or reduces our agility, the solution should include improving the gear, not ignoring it or discounting its importance.

So before you go to work today (every day?), think about what you need to keep yourself and your patients safe. And get your gear on.

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

It’s great to be a Tennessee Volunteer. I said, It’s great to be a Tennessee Volunteer!

The crowd, a sea of orange, packs into Neyland Stadium in Knoxville, Tenn., brimming with pride, dedicated to the team they call the Vols. Neyland Stadium, built in 1921, comfortably seats more than 100,000 brash fans on most fall weekends during the college football season. These die-hard fans pack the stadium regularly, hoping to catch a glimpse of victory.

Throughout the decades of Tennessee Volunteers football, numerous coaches have spent countless hours thinking about how to realize those victories. And they have also spent a lot time thinking about how to keep their players safe. Each coach has had different styles and tactics, but all had one thing in common: They were clearly invested in keeping their players safe. A safe player is a good player, one who can make the full season without injury. As such, before each practice and each game, the players don the gear required to play the safest game possible.

This gear is expensive, difficult to put on, difficult to keep on, makes them run slower, and makes them sweat heavier. When you think about it, it is a wonder that they wear it at all—unless you consider the fact that each precisely placed article takes them one step closer to surviving the game intact, and making it to the next victory. Just like any other type of protective equipment, football equipment has evolved over the course of time. The helmet, for example, is now custom-fit for each player with calipers, and then subsequent additions are applied to ensure durability, shock resistance, and comfort. Relatively new additions include eye shields (to protect the eyes and reduce glare) and even radio devices (to allow the coach to relay last-minute critical information to the quarterback). These helmets are all customized to the players’ position, to allow for the best balance between protection and visibility.

And the helmet is just the beginning. The remaining bare minimum amount of gear needed for standard player safety includes a mouthpiece, jaw pads, neck roll, shoulder pads, shock pads, rib pads, hip pads, knee pads, and cleats. All told, the weight of all this equipment is between 10 and 25 pounds and takes up to an hour to fully gear up. But nonetheless, it has become such a mainstay, of centralized importance to the game, that each team has a dedicated equipment manager. They are charged with providing, maintaining, and transporting the best gear for every member of the team. The equipment manager is a vital resource for the team and the sport.

Despite the extra weight and inconvenience that their gear can burden them with, you don’t see a single football player “skimp” on it. And it would certainly be obvious to all those around them if they ran onto the field without their helmet. Over the years, the football industry has not abandoned gear that they thought was less than perfect, too heavy, too bulky, or made the player perform with less agility. They just made the gear better, lighter, more comfortable, and more protective.

You Can Do This

In a similar fashion, hospital providers have become increasingly interested in keeping themselves—and the patient—safe. But have we come to consensus on who the coach and equipment managers should be, and what the essential elements of the gear should be? I would argue there are a number of coaches and equipment managers in the hospital setting whose mission is to keep their “players” safe. The players are both patients and providers, as generally a “safe provider” is one who makes and implements solid decisions, and who is housed within a safe, predictable, and highly-reliable system, is also one who can and will keep their patients safe.

We may not think of ourselves as such, but hospitalists can be extremely effective coaches and equipment managers. They can help create and maintain safe and effective gear for themselves and those patients and providers around them. They can be a mentor for displaying how vitally import this gear is and can work to improve it when it proves to be imperfect.

Although we don’t tend to think of these things as “safety gear,” these things do, in fact, keep us and our patients safe. Some of these include:

• Computerized physician order entry (CPOE) with decision support (or order sets without CPOE);
• Checklists;
• Procedural time-outs;
• Protocols;
• Medication dosing guidelines;
• Handheld devices (for quick lookup of medication doses, side effects, predictive scoring systems, medical calculators, etc.); and
• Gowns and gloves.

Additional “gear” for the patients can include:

• Arm bands for identification and medication scanning;
• Telemetry;
• Bed alarms;
• IV pumps with guard rails around dosing;
• Antibiotic impregnated central lines; and
• Early mobilization protocols.

The Next Level

To take the medical industry to the next level of safe reliability, we need all providers to accept and embrace the concept of “safety gear” for themselves and for their patients. We need to make it perfectly obvious when that gear is missing. It should invoke a reaction of ghastly fear when we witness anyone (provider, patient, or family) skimping on their gear: removing an armband for convenience, bypassing a smart pump, or skipping decision support in CPOE. And for the current gear that is imperfect, slows us down, beeps too often, or reduces our agility, the solution should include improving the gear, not ignoring it or discounting its importance.

So before you go to work today (every day?), think about what you need to keep yourself and your patients safe. And get your gear on.

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

John Nelson, MD, MHM

Ben was just accepted to med school!!! Hopefully, more acceptances will be forthcoming. We are very proud of Ben for all his hard work. Another doctor in the family.

I was delighted to find the above message from an old friend in my inbox. It got me thinking: Will Ben become a hospitalist? Will he join his dad’s hospitalist group? Will his dad encourage him to pursue a hospitalist career or something else?

Early Hospitalist Practice

The author of that email was Ben’s dad, Chuck Wilson. Chuck is the reason I’m a hospitalist. He was a year ahead of me in residency, and while still a resident, he somehow connected with a really busy family physician in town who was looking for someone to manage his hospital patients. Not one to be bound by convention, Chuck agreed to what was at the time a nearly unheard-of arrangement. He finished residency, joined the staff of the community hospital across town from our residency, and began caring for the family physician’s hospital patients. Within days, he was fielding calls from other doctors asking him to do the same for them. Within weeks of arriving, he had begun accepting essentially all unassigned medical admissions from the ED. This was in the 1980s; Chuck was among the nation’s first real hospitalists.

I don’t think Chuck spent any time worrying about how his practice was so different from the traditional internists and family physicians in the community. He was confident he was providing a valuable service to his patients and the medical community. The rapid growth in his patient census was an indicator he was on to something, and soon he and I began talking. He was looking for a partner.

In November of my third year of residency, I decided I would put off my endocrinology fellowship for a year or two and join Chuck in his new practice. From our conversations, I anticipated that I would care for exactly the kinds of patients that filled nearly all of my time as a resident. I wouldn’t need to learn the new skills in ambulatory medicine, and wouldn’t need to make the long-term commitment expected to join a traditional primary-care practice. And I would earn a competitive compensation and have a flexible lifestyle. I soon realized that hospitalist practice provided me with all of these advantages, so more than two decades later, I still haven’t gotten around to completing the application for an endocrine fellowship.

A Loose Arrangement

For the first few years, Chuck and I didn’t bother to have any sort of legal agreement with each other. We shook hands and agreed to a “reap what you till” form of compensation, which meant we didn’t have to work exactly the same amount, and never had disagreements about how practice revenue was divided between us.

Because of Chuck’s influence, we had miniscule overhead expenses, most likely less than 10% of revenue. We each bought our own malpractice insurance, paid our biller a percent of collections, and rented a pager. That was about it for overhead.

We had no rigid scheduling algorithm, the only requirement being that at least one of us needed to be working every day. Both of us worked most weekdays, but we took time off whenever it suited us. Our scheduling meetings were usually held when we bumped into one another while rounding and went something like this:

“You OK if I take five days off starting tomorrow?”

“Sure. That’s fine.”

Meeting adjourned.

For years, we had no official name for our practice. This became a bigger issue when our group had grown to four doctors, so we defaulted to referring to the group by the first letter of the last name of each doctor, in order of tenure: The WNKL Group. A more formal name was to follow a few years later when the group was even larger, but I’ve taken delight in hearing that WNKL has persisted in some places and documents around the hospital years later, even though N, K, and L left the group long ago.

In the first few years, we never thought about developing clinical protocols or measuring our efficiency or clinical effectiveness. Chuck was confident that compared to the traditional primary-care model, we were providing higher-quality care at a lower cost. But I wasn’t so sure. After a few years, we began seeing hospital data showing that our cost per case tended to be lower, and what little data we could get regarding our quality of care suggested that it was about the same, and in some cases might be better.

A principal reason the practice has survived more than 25 years is that other than a small “tax” during their first 18 months (mainly to cover the cost of recruiting them), new doctors were regarded as equals in the business. Chuck and subsequent doctors never tried to gain an advantage over newer doctors by trying to claim a greater share of the practice’s revenue or decision-making authority.

Chuck is still in the same group he founded. In 2000, I was lured away by the chance to start a new group and live in a place that both my wife and I love. He and I have enjoyed watching our field grow up, and we take satisfaction in our roles in its evolution.

Lessons Learned

The hospitalist model of practice didn’t have a single inventor or place of origin, and anyone involved in starting a practice in the 1980s or before should be proud to have invented their practice when no blueprint existed. Creative thinking and openness to a new way of doing things were critical in developing the first hospitalist practices. They also are useful traits in trying to improve modern hospitalist practices or other segments of our healthcare system.

Like many new developments in medicine, the economic effects of our practice—lower hospital cost per case—became apparent, especially to Chuck, before data regarding quality surfaced. I wish we had gotten more serious early on about capturing whatever quality data might have been available—clearly less than what is available today—and those in new healthcare endeavors today should try to measure quality at the outset. Unlike the 1980s, the current marketplace will help ensure that happens.

Coda

There is one other really cool thing about Chuck’s email at the beginning of this column: those three exclamation points! Chuck is typically laconic and understated, and not given to such displays of emotion, but there are few things that generate more enthusiasm than a parent sharing news of a child’s success.

So, Ben, as you start med school next year, I wish you the best. You can be sure I’ll be asking for updates about your progress. The most important thing is that you find a life and career that engages you to do good work for others and provides satisfaction. And whatever you choose to do after med school, I know you’ll continue to make your parents proud.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is course co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

John Nelson, MD, MHM

Ben was just accepted to med school!!! Hopefully, more acceptances will be forthcoming. We are very proud of Ben for all his hard work. Another doctor in the family.

I was delighted to find the above message from an old friend in my inbox. It got me thinking: Will Ben become a hospitalist? Will he join his dad’s hospitalist group? Will his dad encourage him to pursue a hospitalist career or something else?

Early Hospitalist Practice

The author of that email was Ben’s dad, Chuck Wilson. Chuck is the reason I’m a hospitalist. He was a year ahead of me in residency, and while still a resident, he somehow connected with a really busy family physician in town who was looking for someone to manage his hospital patients. Not one to be bound by convention, Chuck agreed to what was at the time a nearly unheard-of arrangement. He finished residency, joined the staff of the community hospital across town from our residency, and began caring for the family physician’s hospital patients. Within days, he was fielding calls from other doctors asking him to do the same for them. Within weeks of arriving, he had begun accepting essentially all unassigned medical admissions from the ED. This was in the 1980s; Chuck was among the nation’s first real hospitalists.

I don’t think Chuck spent any time worrying about how his practice was so different from the traditional internists and family physicians in the community. He was confident he was providing a valuable service to his patients and the medical community. The rapid growth in his patient census was an indicator he was on to something, and soon he and I began talking. He was looking for a partner.

In November of my third year of residency, I decided I would put off my endocrinology fellowship for a year or two and join Chuck in his new practice. From our conversations, I anticipated that I would care for exactly the kinds of patients that filled nearly all of my time as a resident. I wouldn’t need to learn the new skills in ambulatory medicine, and wouldn’t need to make the long-term commitment expected to join a traditional primary-care practice. And I would earn a competitive compensation and have a flexible lifestyle. I soon realized that hospitalist practice provided me with all of these advantages, so more than two decades later, I still haven’t gotten around to completing the application for an endocrine fellowship.

A Loose Arrangement

For the first few years, Chuck and I didn’t bother to have any sort of legal agreement with each other. We shook hands and agreed to a “reap what you till” form of compensation, which meant we didn’t have to work exactly the same amount, and never had disagreements about how practice revenue was divided between us.

Because of Chuck’s influence, we had miniscule overhead expenses, most likely less than 10% of revenue. We each bought our own malpractice insurance, paid our biller a percent of collections, and rented a pager. That was about it for overhead.

We had no rigid scheduling algorithm, the only requirement being that at least one of us needed to be working every day. Both of us worked most weekdays, but we took time off whenever it suited us. Our scheduling meetings were usually held when we bumped into one another while rounding and went something like this:

“You OK if I take five days off starting tomorrow?”

“Sure. That’s fine.”

Meeting adjourned.

For years, we had no official name for our practice. This became a bigger issue when our group had grown to four doctors, so we defaulted to referring to the group by the first letter of the last name of each doctor, in order of tenure: The WNKL Group. A more formal name was to follow a few years later when the group was even larger, but I’ve taken delight in hearing that WNKL has persisted in some places and documents around the hospital years later, even though N, K, and L left the group long ago.

In the first few years, we never thought about developing clinical protocols or measuring our efficiency or clinical effectiveness. Chuck was confident that compared to the traditional primary-care model, we were providing higher-quality care at a lower cost. But I wasn’t so sure. After a few years, we began seeing hospital data showing that our cost per case tended to be lower, and what little data we could get regarding our quality of care suggested that it was about the same, and in some cases might be better.

A principal reason the practice has survived more than 25 years is that other than a small “tax” during their first 18 months (mainly to cover the cost of recruiting them), new doctors were regarded as equals in the business. Chuck and subsequent doctors never tried to gain an advantage over newer doctors by trying to claim a greater share of the practice’s revenue or decision-making authority.

Chuck is still in the same group he founded. In 2000, I was lured away by the chance to start a new group and live in a place that both my wife and I love. He and I have enjoyed watching our field grow up, and we take satisfaction in our roles in its evolution.

Lessons Learned

The hospitalist model of practice didn’t have a single inventor or place of origin, and anyone involved in starting a practice in the 1980s or before should be proud to have invented their practice when no blueprint existed. Creative thinking and openness to a new way of doing things were critical in developing the first hospitalist practices. They also are useful traits in trying to improve modern hospitalist practices or other segments of our healthcare system.

Like many new developments in medicine, the economic effects of our practice—lower hospital cost per case—became apparent, especially to Chuck, before data regarding quality surfaced. I wish we had gotten more serious early on about capturing whatever quality data might have been available—clearly less than what is available today—and those in new healthcare endeavors today should try to measure quality at the outset. Unlike the 1980s, the current marketplace will help ensure that happens.

Coda

There is one other really cool thing about Chuck’s email at the beginning of this column: those three exclamation points! Chuck is typically laconic and understated, and not given to such displays of emotion, but there are few things that generate more enthusiasm than a parent sharing news of a child’s success.

So, Ben, as you start med school next year, I wish you the best. You can be sure I’ll be asking for updates about your progress. The most important thing is that you find a life and career that engages you to do good work for others and provides satisfaction. And whatever you choose to do after med school, I know you’ll continue to make your parents proud.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is course co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

John Nelson, MD, MHM

Ben was just accepted to med school!!! Hopefully, more acceptances will be forthcoming. We are very proud of Ben for all his hard work. Another doctor in the family.

I was delighted to find the above message from an old friend in my inbox. It got me thinking: Will Ben become a hospitalist? Will he join his dad’s hospitalist group? Will his dad encourage him to pursue a hospitalist career or something else?

Early Hospitalist Practice

The author of that email was Ben’s dad, Chuck Wilson. Chuck is the reason I’m a hospitalist. He was a year ahead of me in residency, and while still a resident, he somehow connected with a really busy family physician in town who was looking for someone to manage his hospital patients. Not one to be bound by convention, Chuck agreed to what was at the time a nearly unheard-of arrangement. He finished residency, joined the staff of the community hospital across town from our residency, and began caring for the family physician’s hospital patients. Within days, he was fielding calls from other doctors asking him to do the same for them. Within weeks of arriving, he had begun accepting essentially all unassigned medical admissions from the ED. This was in the 1980s; Chuck was among the nation’s first real hospitalists.

I don’t think Chuck spent any time worrying about how his practice was so different from the traditional internists and family physicians in the community. He was confident he was providing a valuable service to his patients and the medical community. The rapid growth in his patient census was an indicator he was on to something, and soon he and I began talking. He was looking for a partner.

In November of my third year of residency, I decided I would put off my endocrinology fellowship for a year or two and join Chuck in his new practice. From our conversations, I anticipated that I would care for exactly the kinds of patients that filled nearly all of my time as a resident. I wouldn’t need to learn the new skills in ambulatory medicine, and wouldn’t need to make the long-term commitment expected to join a traditional primary-care practice. And I would earn a competitive compensation and have a flexible lifestyle. I soon realized that hospitalist practice provided me with all of these advantages, so more than two decades later, I still haven’t gotten around to completing the application for an endocrine fellowship.

A Loose Arrangement

For the first few years, Chuck and I didn’t bother to have any sort of legal agreement with each other. We shook hands and agreed to a “reap what you till” form of compensation, which meant we didn’t have to work exactly the same amount, and never had disagreements about how practice revenue was divided between us.

Because of Chuck’s influence, we had miniscule overhead expenses, most likely less than 10% of revenue. We each bought our own malpractice insurance, paid our biller a percent of collections, and rented a pager. That was about it for overhead.

We had no rigid scheduling algorithm, the only requirement being that at least one of us needed to be working every day. Both of us worked most weekdays, but we took time off whenever it suited us. Our scheduling meetings were usually held when we bumped into one another while rounding and went something like this:

“You OK if I take five days off starting tomorrow?”

“Sure. That’s fine.”

Meeting adjourned.

For years, we had no official name for our practice. This became a bigger issue when our group had grown to four doctors, so we defaulted to referring to the group by the first letter of the last name of each doctor, in order of tenure: The WNKL Group. A more formal name was to follow a few years later when the group was even larger, but I’ve taken delight in hearing that WNKL has persisted in some places and documents around the hospital years later, even though N, K, and L left the group long ago.

In the first few years, we never thought about developing clinical protocols or measuring our efficiency or clinical effectiveness. Chuck was confident that compared to the traditional primary-care model, we were providing higher-quality care at a lower cost. But I wasn’t so sure. After a few years, we began seeing hospital data showing that our cost per case tended to be lower, and what little data we could get regarding our quality of care suggested that it was about the same, and in some cases might be better.

A principal reason the practice has survived more than 25 years is that other than a small “tax” during their first 18 months (mainly to cover the cost of recruiting them), new doctors were regarded as equals in the business. Chuck and subsequent doctors never tried to gain an advantage over newer doctors by trying to claim a greater share of the practice’s revenue or decision-making authority.

Chuck is still in the same group he founded. In 2000, I was lured away by the chance to start a new group and live in a place that both my wife and I love. He and I have enjoyed watching our field grow up, and we take satisfaction in our roles in its evolution.

Lessons Learned

The hospitalist model of practice didn’t have a single inventor or place of origin, and anyone involved in starting a practice in the 1980s or before should be proud to have invented their practice when no blueprint existed. Creative thinking and openness to a new way of doing things were critical in developing the first hospitalist practices. They also are useful traits in trying to improve modern hospitalist practices or other segments of our healthcare system.

Like many new developments in medicine, the economic effects of our practice—lower hospital cost per case—became apparent, especially to Chuck, before data regarding quality surfaced. I wish we had gotten more serious early on about capturing whatever quality data might have been available—clearly less than what is available today—and those in new healthcare endeavors today should try to measure quality at the outset. Unlike the 1980s, the current marketplace will help ensure that happens.

Coda

There is one other really cool thing about Chuck’s email at the beginning of this column: those three exclamation points! Chuck is typically laconic and understated, and not given to such displays of emotion, but there are few things that generate more enthusiasm than a parent sharing news of a child’s success.

So, Ben, as you start med school next year, I wish you the best. You can be sure I’ll be asking for updates about your progress. The most important thing is that you find a life and career that engages you to do good work for others and provides satisfaction. And whatever you choose to do after med school, I know you’ll continue to make your parents proud.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is course co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Patient Transfers

Hospitalist billing depends on several factors. Know your role and avoid common mistakes Patient transfers can occur for many reasons: advanced technological services required, health insurance coverage, or a change in the level of care, to name a few. Patient care that is provided in the acute-care setting does not always terminate with discharge to home. Frequently, hospitalists are involved in patient transfers to another location to receive additional services: intrafacility (a different unit or related facility within the same physical plant) or interfacility (geographically separate facilities). The hospitalist must identify his or her role in the transfer and the patient’s new environment.

Physician billing in the transferred setting depends upon several factors:¹

• Shared or merged medical record;
• The attending of record in each setting;
• The requirements for care rendered by the hospitalist in each setting; and
• Service dates.

Intrafacility Initial Service

Let’s examine a common example: A hospitalist serves as the “attending of record” in an inpatient hospital where acute care is required for an 83-year-old female with hypertension and diabetes who sustained a left hip fracture. The hospitalist plans to discharge the patient to the rehabilitation unit. After transfer, the rehabilitation physician becomes the attending of record, and the hospitalist might be asked to provide ongoing care for the patient’s hypertension and diabetes.

What should the hospitalist report for the initial post-transfer service? The typical options to consider are:²

• Inpatient consultation (99251-99255);
• Initial hospital care (99221-99223); and
• Subsequent hospital care (99231-99233).

Report a consultation only if the rehab attending requests an opinion or advice for an unrelated, new condition instead of previously treated conditions, and the requesting physician’s intent is for opinion or advice on management options rather than the a priori intent for the hospitalist to assume the patient’s medical care. If these requirements are met, the hospitalist may report an inpatient consultation code (99251-99255). Alternatively, if the intent or need represents a continuity of medical care provided during the acute episode of care, report the most appropriate subsequent hospital care code (99231-99233) for the hospitalist’s initial rehab visit and all follow-up services.

Initial hospital care (99221-99223) codes can only be reported for Medicare beneficiaries in place of consultation codes (99251-99255), as Medicare ceased to reimburse consultation codes.³ Most other payors who do not recognize consultation services only allow one initial hospital care code per hospitalization, reserved for the attending of record.

Interfacility Initial Service

Hospitalist groups provide patient care and coverage in many different types of facilities. Confusion often arises when the “attending of record” during acute care and the “subacute” setting (e.g. long-term acute-care hospital) are two different hospitalists from the same group practice. The hospitalist receiving the patient in the transfer facility may decide to report subsequent hospital care (99231-99233), because the group has been providing ongoing care to this patient. In this scenario, the hospitalist group could be losing revenue if an admission service (99221-99223) was not reported.

An initial hospital care service (99221-99223) is permitted when the transfer is between:

• Different hospitals;
• Different facilities under common ownership which do not have merged records; or
• Between the acute-care hospital and a PPS (prospective payment system)-exempt unit within the same hospital when there are no merged records (e.g. Medicare Part A-covered inpatient care in psychiatric, rehabilitation, critical access, and long-term care hospitals).⁴

In all other transfer circumstances not meeting the elements noted above, the physician should bill only the appropriate level of subsequent hospital care (99231-99233) for the date of transfer.¹ Do not equate “merged records” to commonly accessible charts via an electronic medical record system or an electronic storage system. If the medical record for the patient’s acute stay is “closed” and the patient is given a separate medical record and registration for the stay in the transferred facility, consider the transfer stay as a separate admission.

Billing Two Services on Day of Transfer

Whether the transfer is classified as intrafacility or interfacility, an individual hospitalist or two separate hospitalists from the same group practice may provide the acute-care discharge and the transfer admission. A hospital discharge day management service (99238-99239) and an initial hospital care service (99221-99223) can only be reported if they do not occur on the same day.¹ Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician; if more than one evaluation and management (face to face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported.⁵

The Exception

CMS will allow a single hospitalist or two hospitalists from the same group practice to report a discharge day management service on the same day as an admission service. When they are billed by the same physician or group with the same date of service, contractors are instructed to pay the hospital discharge day management code (99238-99239) in addition to a nursing facility admission code (99304-99306).⁶

Conversely, if the patient is admitted to a hospital (99221-99223) following a nursing facility discharge (99315-99316) on the same date by the same physician/group, insurers will only reimburse the initial hospital care code. Payment for the initial hospital care service includes all work performed by the physician/group in all sites of service on that date.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is faculty for SHM’s inpatient coding course.

References available online at the-hospitalist.org

ICD-10 Update

On Sept. 5, 2012, the Centers for Medicare & Medicaid Services (CMS) published the final rule for Administration Simplification, which included a compliance date change for the International Classification of Diseases, 10th Edition (ICD-10-CM and ICD-10-PCS), Medical Data Code Sets:⁷

“According to a recent survey conducted by the CMS, up to one-quarter of healthcare providers believe they will not be ready for an October 1, 2013, compliance date. While the survey found no significant differences among practice settings regarding the likelihood of achieving compliance before the deadline, based on recent industry feedback we believe that larger healthcare plans and providers generally are more prepared than smaller entities. The uncertainty about provider readiness is confirmed in another recent readiness survey in which nearly 50 percent of the 2,140 provider respondents did not know when they would complete their impact assessment of the ICD-10 transition. By delaying the compliance date of ICD-10 from October 1, 2013, to October 1, 2014, we are allowing more time for covered entities to prepare for the transition to ICD-10 and to conduct thorough testing. By allowing more time to prepare, covered entities may be able to avoid costly obstacles that would otherwise emerge while in production.”⁷

Although providers have gained a year to adopt ICD-10, this should not deter progress toward the 2014 goal, with hopefulness that additional rulings will be made to further stall full implementation.

Patient Transfers

Hospitalist billing depends on several factors. Know your role and avoid common mistakes Patient transfers can occur for many reasons: advanced technological services required, health insurance coverage, or a change in the level of care, to name a few. Patient care that is provided in the acute-care setting does not always terminate with discharge to home. Frequently, hospitalists are involved in patient transfers to another location to receive additional services: intrafacility (a different unit or related facility within the same physical plant) or interfacility (geographically separate facilities). The hospitalist must identify his or her role in the transfer and the patient’s new environment.

Physician billing in the transferred setting depends upon several factors:¹

• Shared or merged medical record;
• The attending of record in each setting;
• The requirements for care rendered by the hospitalist in each setting; and
• Service dates.

Intrafacility Initial Service

Let’s examine a common example: A hospitalist serves as the “attending of record” in an inpatient hospital where acute care is required for an 83-year-old female with hypertension and diabetes who sustained a left hip fracture. The hospitalist plans to discharge the patient to the rehabilitation unit. After transfer, the rehabilitation physician becomes the attending of record, and the hospitalist might be asked to provide ongoing care for the patient’s hypertension and diabetes.

What should the hospitalist report for the initial post-transfer service? The typical options to consider are:²

• Inpatient consultation (99251-99255);
• Initial hospital care (99221-99223); and
• Subsequent hospital care (99231-99233).

Report a consultation only if the rehab attending requests an opinion or advice for an unrelated, new condition instead of previously treated conditions, and the requesting physician’s intent is for opinion or advice on management options rather than the a priori intent for the hospitalist to assume the patient’s medical care. If these requirements are met, the hospitalist may report an inpatient consultation code (99251-99255). Alternatively, if the intent or need represents a continuity of medical care provided during the acute episode of care, report the most appropriate subsequent hospital care code (99231-99233) for the hospitalist’s initial rehab visit and all follow-up services.

Initial hospital care (99221-99223) codes can only be reported for Medicare beneficiaries in place of consultation codes (99251-99255), as Medicare ceased to reimburse consultation codes.³ Most other payors who do not recognize consultation services only allow one initial hospital care code per hospitalization, reserved for the attending of record.

Interfacility Initial Service

Hospitalist groups provide patient care and coverage in many different types of facilities. Confusion often arises when the “attending of record” during acute care and the “subacute” setting (e.g. long-term acute-care hospital) are two different hospitalists from the same group practice. The hospitalist receiving the patient in the transfer facility may decide to report subsequent hospital care (99231-99233), because the group has been providing ongoing care to this patient. In this scenario, the hospitalist group could be losing revenue if an admission service (99221-99223) was not reported.

An initial hospital care service (99221-99223) is permitted when the transfer is between:

• Different hospitals;
• Different facilities under common ownership which do not have merged records; or
• Between the acute-care hospital and a PPS (prospective payment system)-exempt unit within the same hospital when there are no merged records (e.g. Medicare Part A-covered inpatient care in psychiatric, rehabilitation, critical access, and long-term care hospitals).⁴

In all other transfer circumstances not meeting the elements noted above, the physician should bill only the appropriate level of subsequent hospital care (99231-99233) for the date of transfer.¹ Do not equate “merged records” to commonly accessible charts via an electronic medical record system or an electronic storage system. If the medical record for the patient’s acute stay is “closed” and the patient is given a separate medical record and registration for the stay in the transferred facility, consider the transfer stay as a separate admission.

Billing Two Services on Day of Transfer

Whether the transfer is classified as intrafacility or interfacility, an individual hospitalist or two separate hospitalists from the same group practice may provide the acute-care discharge and the transfer admission. A hospital discharge day management service (99238-99239) and an initial hospital care service (99221-99223) can only be reported if they do not occur on the same day.¹ Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician; if more than one evaluation and management (face to face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported.⁵

The Exception

CMS will allow a single hospitalist or two hospitalists from the same group practice to report a discharge day management service on the same day as an admission service. When they are billed by the same physician or group with the same date of service, contractors are instructed to pay the hospital discharge day management code (99238-99239) in addition to a nursing facility admission code (99304-99306).⁶

Conversely, if the patient is admitted to a hospital (99221-99223) following a nursing facility discharge (99315-99316) on the same date by the same physician/group, insurers will only reimburse the initial hospital care code. Payment for the initial hospital care service includes all work performed by the physician/group in all sites of service on that date.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is faculty for SHM’s inpatient coding course.

References available online at the-hospitalist.org

ICD-10 Update

On Sept. 5, 2012, the Centers for Medicare & Medicaid Services (CMS) published the final rule for Administration Simplification, which included a compliance date change for the International Classification of Diseases, 10th Edition (ICD-10-CM and ICD-10-PCS), Medical Data Code Sets:⁷

“According to a recent survey conducted by the CMS, up to one-quarter of healthcare providers believe they will not be ready for an October 1, 2013, compliance date. While the survey found no significant differences among practice settings regarding the likelihood of achieving compliance before the deadline, based on recent industry feedback we believe that larger healthcare plans and providers generally are more prepared than smaller entities. The uncertainty about provider readiness is confirmed in another recent readiness survey in which nearly 50 percent of the 2,140 provider respondents did not know when they would complete their impact assessment of the ICD-10 transition. By delaying the compliance date of ICD-10 from October 1, 2013, to October 1, 2014, we are allowing more time for covered entities to prepare for the transition to ICD-10 and to conduct thorough testing. By allowing more time to prepare, covered entities may be able to avoid costly obstacles that would otherwise emerge while in production.”⁷

Although providers have gained a year to adopt ICD-10, this should not deter progress toward the 2014 goal, with hopefulness that additional rulings will be made to further stall full implementation.

Patient Transfers

Hospitalist billing depends on several factors. Know your role and avoid common mistakes Patient transfers can occur for many reasons: advanced technological services required, health insurance coverage, or a change in the level of care, to name a few. Patient care that is provided in the acute-care setting does not always terminate with discharge to home. Frequently, hospitalists are involved in patient transfers to another location to receive additional services: intrafacility (a different unit or related facility within the same physical plant) or interfacility (geographically separate facilities). The hospitalist must identify his or her role in the transfer and the patient’s new environment.

Physician billing in the transferred setting depends upon several factors:¹

• Shared or merged medical record;
• The attending of record in each setting;
• The requirements for care rendered by the hospitalist in each setting; and
• Service dates.

Intrafacility Initial Service

Let’s examine a common example: A hospitalist serves as the “attending of record” in an inpatient hospital where acute care is required for an 83-year-old female with hypertension and diabetes who sustained a left hip fracture. The hospitalist plans to discharge the patient to the rehabilitation unit. After transfer, the rehabilitation physician becomes the attending of record, and the hospitalist might be asked to provide ongoing care for the patient’s hypertension and diabetes.

What should the hospitalist report for the initial post-transfer service? The typical options to consider are:²

• Inpatient consultation (99251-99255);
• Initial hospital care (99221-99223); and
• Subsequent hospital care (99231-99233).

Report a consultation only if the rehab attending requests an opinion or advice for an unrelated, new condition instead of previously treated conditions, and the requesting physician’s intent is for opinion or advice on management options rather than the a priori intent for the hospitalist to assume the patient’s medical care. If these requirements are met, the hospitalist may report an inpatient consultation code (99251-99255). Alternatively, if the intent or need represents a continuity of medical care provided during the acute episode of care, report the most appropriate subsequent hospital care code (99231-99233) for the hospitalist’s initial rehab visit and all follow-up services.

Initial hospital care (99221-99223) codes can only be reported for Medicare beneficiaries in place of consultation codes (99251-99255), as Medicare ceased to reimburse consultation codes.³ Most other payors who do not recognize consultation services only allow one initial hospital care code per hospitalization, reserved for the attending of record.

Interfacility Initial Service

Hospitalist groups provide patient care and coverage in many different types of facilities. Confusion often arises when the “attending of record” during acute care and the “subacute” setting (e.g. long-term acute-care hospital) are two different hospitalists from the same group practice. The hospitalist receiving the patient in the transfer facility may decide to report subsequent hospital care (99231-99233), because the group has been providing ongoing care to this patient. In this scenario, the hospitalist group could be losing revenue if an admission service (99221-99223) was not reported.

An initial hospital care service (99221-99223) is permitted when the transfer is between:

• Different hospitals;
• Different facilities under common ownership which do not have merged records; or
• Between the acute-care hospital and a PPS (prospective payment system)-exempt unit within the same hospital when there are no merged records (e.g. Medicare Part A-covered inpatient care in psychiatric, rehabilitation, critical access, and long-term care hospitals).⁴

In all other transfer circumstances not meeting the elements noted above, the physician should bill only the appropriate level of subsequent hospital care (99231-99233) for the date of transfer.¹ Do not equate “merged records” to commonly accessible charts via an electronic medical record system or an electronic storage system. If the medical record for the patient’s acute stay is “closed” and the patient is given a separate medical record and registration for the stay in the transferred facility, consider the transfer stay as a separate admission.

Billing Two Services on Day of Transfer

Whether the transfer is classified as intrafacility or interfacility, an individual hospitalist or two separate hospitalists from the same group practice may provide the acute-care discharge and the transfer admission. A hospital discharge day management service (99238-99239) and an initial hospital care service (99221-99223) can only be reported if they do not occur on the same day.¹ Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician; if more than one evaluation and management (face to face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported.⁵

The Exception

CMS will allow a single hospitalist or two hospitalists from the same group practice to report a discharge day management service on the same day as an admission service. When they are billed by the same physician or group with the same date of service, contractors are instructed to pay the hospital discharge day management code (99238-99239) in addition to a nursing facility admission code (99304-99306).⁶

Conversely, if the patient is admitted to a hospital (99221-99223) following a nursing facility discharge (99315-99316) on the same date by the same physician/group, insurers will only reimburse the initial hospital care code. Payment for the initial hospital care service includes all work performed by the physician/group in all sites of service on that date.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is faculty for SHM’s inpatient coding course.

References available online at the-hospitalist.org

ICD-10 Update

On Sept. 5, 2012, the Centers for Medicare & Medicaid Services (CMS) published the final rule for Administration Simplification, which included a compliance date change for the International Classification of Diseases, 10th Edition (ICD-10-CM and ICD-10-PCS), Medical Data Code Sets:⁷

“According to a recent survey conducted by the CMS, up to one-quarter of healthcare providers believe they will not be ready for an October 1, 2013, compliance date. While the survey found no significant differences among practice settings regarding the likelihood of achieving compliance before the deadline, based on recent industry feedback we believe that larger healthcare plans and providers generally are more prepared than smaller entities. The uncertainty about provider readiness is confirmed in another recent readiness survey in which nearly 50 percent of the 2,140 provider respondents did not know when they would complete their impact assessment of the ICD-10 transition. By delaying the compliance date of ICD-10 from October 1, 2013, to October 1, 2014, we are allowing more time for covered entities to prepare for the transition to ICD-10 and to conduct thorough testing. By allowing more time to prepare, covered entities may be able to avoid costly obstacles that would otherwise emerge while in production.”⁷

Although providers have gained a year to adopt ICD-10, this should not deter progress toward the 2014 goal, with hopefulness that additional rulings will be made to further stall full implementation.

Dr. Hospitalist

Position Paper Did Not Address Family Practice Physicians in ICU

I just finished reading “The Critical-Care Debate” article in The Hospitalist’s October issue. I was quite interested in getting further follow-up and comments regarding family practice physicians’ role in critical care. Now that some hospitalist programs are utilized as “intensivists,” what are SHM and the Society of Critical Care Medicine’s (SCCM) opinions of family practitioners who are hospitalists acting in this manner? The TH article says that internal-medicine programs are insufficient for preparing internists; what are SHM and SCCM’s positions and opinions of family practice physicians being utilized as intensivists?

—Ray Nowaczyk, DO

Dr. Hospitalist responds:

Boy, and we thought this issue was politically charged before you asked that question. From my reading of the position paper (J Hosp Med. 2012;7:359-364) cited in the article, the role of family practice physicians is only alluded to, and not addressed except by its absence. The main thrust of the paper focuses specifically on physicians trained in internal medicine (IM) and how they could become “qualified” to provide ICU care. A few items stand out:

1. The baseline assumption is that these would be IM-trained physicians, not family practice physicians.
2. The requirements to entry wouldinclude: a) completion of IM residency; b) three years’ clinical practice as a hospitalist; and c) enrollment in the ABIM Focused Practice in Hospital Medicine Maintenance of Certification process, which, by definition, requires board certification in internal medicine.

Judging by the vocal backlash from the American College of Chest Physicians (ACCP), I imagine that even getting consensus on the points above required some fairly heavy lifting. Addressing the issue of family practitioners in HM likely was not a topic they felt could gain traction

You are absolutely correct, though, in that plenty of family practitioners practice full time as adult hospitalists (and are doing a fine job). As the paper notes, it is estimated that 6% to 8% of all hospitalists are familypractice- trained. Unfortunately, there is very little objective documentation that will allow them to demonstrate their clinical quality other than direct clinical practice or observation. There is no formal “bridge” to cross for a family practice physician wanting to receive certification in hospital medicine; this currently can only happen through ABIM.

At the same time, I do not believe that the absence of formal certification disqualifies any family practitioner from practicing quality medicine in the hospital. In fact, in my market, there are some fantastic family practice hospitalists who have been in practice in a busy, urban, Level I hospital for more than 10 years. They clearly have the clinical experience and skills that would vastly outweigh those of almost any new graduate of an internal-medicine program. Can they prove it? Not today.

I think it’s a similar discussion with IM-trained hospitalists providing ICU care. I have colleagues who actively seek to accept and care for ICU patients when it comes time for admissions, and these physicians spend much more time in direct patient care in the ICU than even some of our intensivists. Can they prove their skills? Not today. However, as noted in the Leapfrog data, at this point, only 4% of ICUs have 24/7 dedicated intensivists, so who are we kidding? We need hospitalists to provide competent ICU care. Whether we provide a pathway for objective recognition or not, it is still going to happen. It sure would be nice if it happened in a sensible way with input from the stakeholders—just as was suggested in the position paper.

Here’s a little anecdote: Many years ago, there was an ortho PA (we’ll call him Jimmy John) in our hospital, but when you called his pager number, which he also gave out routinely to patients, the message said, “You’ve reached the pager of Doctor John.” He was no doctor. Well, one of us finally asked him about it, and he replied, with a straight face: “Oh, I used to be a vet.” OK.

The point is, we all need to recognize our own skills and limitations and be able to communicate those same skills and limitations to others, especially to patients, honestly. Since honesty has its limits, then independent objective measurement is a useful adjunct. Just look at your office walls.

Dr. Hospitalist

Position Paper Did Not Address Family Practice Physicians in ICU

I just finished reading “The Critical-Care Debate” article in The Hospitalist’s October issue. I was quite interested in getting further follow-up and comments regarding family practice physicians’ role in critical care. Now that some hospitalist programs are utilized as “intensivists,” what are SHM and the Society of Critical Care Medicine’s (SCCM) opinions of family practitioners who are hospitalists acting in this manner? The TH article says that internal-medicine programs are insufficient for preparing internists; what are SHM and SCCM’s positions and opinions of family practice physicians being utilized as intensivists?

—Ray Nowaczyk, DO

Dr. Hospitalist responds:

Boy, and we thought this issue was politically charged before you asked that question. From my reading of the position paper (J Hosp Med. 2012;7:359-364) cited in the article, the role of family practice physicians is only alluded to, and not addressed except by its absence. The main thrust of the paper focuses specifically on physicians trained in internal medicine (IM) and how they could become “qualified” to provide ICU care. A few items stand out:

1. The baseline assumption is that these would be IM-trained physicians, not family practice physicians.
2. The requirements to entry wouldinclude: a) completion of IM residency; b) three years’ clinical practice as a hospitalist; and c) enrollment in the ABIM Focused Practice in Hospital Medicine Maintenance of Certification process, which, by definition, requires board certification in internal medicine.

Judging by the vocal backlash from the American College of Chest Physicians (ACCP), I imagine that even getting consensus on the points above required some fairly heavy lifting. Addressing the issue of family practitioners in HM likely was not a topic they felt could gain traction

You are absolutely correct, though, in that plenty of family practitioners practice full time as adult hospitalists (and are doing a fine job). As the paper notes, it is estimated that 6% to 8% of all hospitalists are familypractice- trained. Unfortunately, there is very little objective documentation that will allow them to demonstrate their clinical quality other than direct clinical practice or observation. There is no formal “bridge” to cross for a family practice physician wanting to receive certification in hospital medicine; this currently can only happen through ABIM.

At the same time, I do not believe that the absence of formal certification disqualifies any family practitioner from practicing quality medicine in the hospital. In fact, in my market, there are some fantastic family practice hospitalists who have been in practice in a busy, urban, Level I hospital for more than 10 years. They clearly have the clinical experience and skills that would vastly outweigh those of almost any new graduate of an internal-medicine program. Can they prove it? Not today.

I think it’s a similar discussion with IM-trained hospitalists providing ICU care. I have colleagues who actively seek to accept and care for ICU patients when it comes time for admissions, and these physicians spend much more time in direct patient care in the ICU than even some of our intensivists. Can they prove their skills? Not today. However, as noted in the Leapfrog data, at this point, only 4% of ICUs have 24/7 dedicated intensivists, so who are we kidding? We need hospitalists to provide competent ICU care. Whether we provide a pathway for objective recognition or not, it is still going to happen. It sure would be nice if it happened in a sensible way with input from the stakeholders—just as was suggested in the position paper.

Here’s a little anecdote: Many years ago, there was an ortho PA (we’ll call him Jimmy John) in our hospital, but when you called his pager number, which he also gave out routinely to patients, the message said, “You’ve reached the pager of Doctor John.” He was no doctor. Well, one of us finally asked him about it, and he replied, with a straight face: “Oh, I used to be a vet.” OK.

The point is, we all need to recognize our own skills and limitations and be able to communicate those same skills and limitations to others, especially to patients, honestly. Since honesty has its limits, then independent objective measurement is a useful adjunct. Just look at your office walls.

Dr. Hospitalist

Position Paper Did Not Address Family Practice Physicians in ICU

I just finished reading “The Critical-Care Debate” article in The Hospitalist’s October issue. I was quite interested in getting further follow-up and comments regarding family practice physicians’ role in critical care. Now that some hospitalist programs are utilized as “intensivists,” what are SHM and the Society of Critical Care Medicine’s (SCCM) opinions of family practitioners who are hospitalists acting in this manner? The TH article says that internal-medicine programs are insufficient for preparing internists; what are SHM and SCCM’s positions and opinions of family practice physicians being utilized as intensivists?

—Ray Nowaczyk, DO

Dr. Hospitalist responds:

Boy, and we thought this issue was politically charged before you asked that question. From my reading of the position paper (J Hosp Med. 2012;7:359-364) cited in the article, the role of family practice physicians is only alluded to, and not addressed except by its absence. The main thrust of the paper focuses specifically on physicians trained in internal medicine (IM) and how they could become “qualified” to provide ICU care. A few items stand out:

1. The baseline assumption is that these would be IM-trained physicians, not family practice physicians.
2. The requirements to entry wouldinclude: a) completion of IM residency; b) three years’ clinical practice as a hospitalist; and c) enrollment in the ABIM Focused Practice in Hospital Medicine Maintenance of Certification process, which, by definition, requires board certification in internal medicine.

Judging by the vocal backlash from the American College of Chest Physicians (ACCP), I imagine that even getting consensus on the points above required some fairly heavy lifting. Addressing the issue of family practitioners in HM likely was not a topic they felt could gain traction

You are absolutely correct, though, in that plenty of family practitioners practice full time as adult hospitalists (and are doing a fine job). As the paper notes, it is estimated that 6% to 8% of all hospitalists are familypractice- trained. Unfortunately, there is very little objective documentation that will allow them to demonstrate their clinical quality other than direct clinical practice or observation. There is no formal “bridge” to cross for a family practice physician wanting to receive certification in hospital medicine; this currently can only happen through ABIM.

At the same time, I do not believe that the absence of formal certification disqualifies any family practitioner from practicing quality medicine in the hospital. In fact, in my market, there are some fantastic family practice hospitalists who have been in practice in a busy, urban, Level I hospital for more than 10 years. They clearly have the clinical experience and skills that would vastly outweigh those of almost any new graduate of an internal-medicine program. Can they prove it? Not today.

I think it’s a similar discussion with IM-trained hospitalists providing ICU care. I have colleagues who actively seek to accept and care for ICU patients when it comes time for admissions, and these physicians spend much more time in direct patient care in the ICU than even some of our intensivists. Can they prove their skills? Not today. However, as noted in the Leapfrog data, at this point, only 4% of ICUs have 24/7 dedicated intensivists, so who are we kidding? We need hospitalists to provide competent ICU care. Whether we provide a pathway for objective recognition or not, it is still going to happen. It sure would be nice if it happened in a sensible way with input from the stakeholders—just as was suggested in the position paper.

Here’s a little anecdote: Many years ago, there was an ortho PA (we’ll call him Jimmy John) in our hospital, but when you called his pager number, which he also gave out routinely to patients, the message said, “You’ve reached the pager of Doctor John.” He was no doctor. Well, one of us finally asked him about it, and he replied, with a straight face: “Oh, I used to be a vet.” OK.

The point is, we all need to recognize our own skills and limitations and be able to communicate those same skills and limitations to others, especially to patients, honestly. Since honesty has its limits, then independent objective measurement is a useful adjunct. Just look at your office walls.