Hospitalists often are involved in the postoperative care of the surgical patient. However, HM is emerging in the admitting/attending role for procedural patients. Confusion can arise as to the nature of the hospitalist service, and whether it is deemed billable. Knowing the surgical package requirements can help hospitalists consider the issues.

Global Surgical Package Period¹

Surgical procedures, categorized as major or minor surgery, are reimbursed for pre-, intra-, and postoperative care. Postoperative care varies according to the procedure’s assigned global period, which designates zero, 10, or 90 postoperative days. (Physicians can review the global period for any given CPT code in the Medicare Physician Fee Schedule, available at www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx.)

Services classified with “XXX” do not have the global period concept. “ZZZ” services denote an “add-on” procedure code that must always be reported with a primary procedure code and assumes the global period assigned to the primary procedure performed.

Major surgery allocates a 90-day global period in which the surgeon is responsible for all related surgical care one day before surgery through 90 postoperative days with no additional charge. Minor surgery, including endoscopy, appoints a zero-day or 10-day postoperative period. The zero-day global period encompasses only services provided on the surgical day, whereas 10-day global periods include services on the surgical day through 10 postoperative days.

Global Surgical Package Components²

The global surgical package comprises a host of responsibilities that include standard facility requirements of filling out all necessary paperwork involved in surgical cases (e.g. preoperative H&P, operative consent forms, preoperative orders). Additionally, the surgeon’s packaged payment includes (at no extra charge):

• Preoperative visits after making the decision for surgery beginning one day prior to surgery;
• All additional postoperative medical or surgical services provided by the surgeon related to complications but not requiring additional trips to the operating room;
• Postoperative visits by the surgeon related to recovery from surgery, including but not limited to dressing changes; local incisional care; removal of cutaneous sutures and staples; line removals; changes and removal of tracheostomy tubes; and discharge services; and
• Postoperative pain management provided by the surgeon.
• Examples of services that are not included in the global surgical package, (i.e. are separately billable and may require an appropriate modifier) are:
• The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery;
• Services of other physicians except where the other physicians are providing coverage for the surgeon or agree on a transfer of care (i.e. a formal agreement in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record);
• Postoperative visits by the surgeon unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery;
• Diagnostic tests and procedures, including diagnostic radiological procedures;
• Clearly distinct surgical procedures during the postoperative period that do not result in repeat operations or treatment for complications;
• Treatment for postoperative complications that requires a return trip to the operating room (OR), catheterization lab or endoscopy suite;
• Immunosuppressive therapy for organ transplants; and
• Critical-care services (CPT codes 99291 and 99292) unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance of the surgeon.

Classification of “Surgeon”

For billing purposes, the “surgeon” is a qualified physician who can perform “surgical” services within their scope of practice. All physicians with the same specialty designation in the same group practice as the “surgeon” (i.e. reporting services under the same tax identification number) are considered a single entity and must adhere to the global period billing rules initiated by the “surgeon.”

Alternately, physicians with different specialty designations in the same group practice (e.g. a hospitalist and a cardiologist in a multispecialty group who report services under the same tax identification number) or different group practices can perform and separately report medically necessary services during the surgeon’s global period, as long as a formal (mutually agreed-upon) transfer of care did not occur.

Medical Necessity

With the growth of HM programs and the admission/attending role expansion, involvement in surgical cases comes under scrutiny for medical necessity. Admitting a patient who has active medical conditions (e.g. hypertension, diabetes, emphysema) is reasonable and necessary because the patient has a well-defined need for medical management by the hospitalist. Participation in the care of these patients is separately billable from the surgeon’s global period package.

Alternatively, a hospitalist might be required to admit and follow surgical patients who have no other identifiable chronic or acute conditions aside from the surgical problem. In these cases, hospitalist involvement may satisfy facility policy (quality of care, risk reduction, etc.) and administrative functions (discharge services or coordination of care) rather than active clinical management. This “medical management” will not be considered “medically necessary” by the payor, and may be denied as incidental to the surgeon’s perioperative services. Erroneous payment can occur, which will result in refund requests, as payors do not want to pay twice for duplicate services. Hospitalists can attempt to negotiate other terms with facilities to account for the unpaid time and effort directed toward these types of cases.

Consider the Case

A patient with numerous medical comorbidities is admitted to the hospitalist service for stabilization prior to surgery, which will occur the next day. The hospitalist can report the appropriate admission code (99221-99223) without need for modifiers because the hospitalist is the attending of record and in a different specialty group. If a private insurer denies the claim as inclusive to the surgical service, the hospitalist can appeal with notes and a cover letter, along with the Medicare guidelines for global surgical package. The hospitalist may continue to provide postoperative daily care, as needed, to manage the patient’s chronic conditions, and report each service as subsequent hospital care (99231-99233) without modifier until the day of discharge (99238-99239). Again, if a payor issues a denial (inclusive to surgery), appealing with notes might be necessary.

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

1. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 40. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. Accessed May 5, 2012.
2. Centers for Medicare & Medicaid Services. ICD-10: HHS proposes one-year delay of ICD-10 compliance date. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/ICD10. Accessed May 5, 2012.
3. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011.

Hospitalists often are involved in the postoperative care of the surgical patient. However, HM is emerging in the admitting/attending role for procedural patients. Confusion can arise as to the nature of the hospitalist service, and whether it is deemed billable. Knowing the surgical package requirements can help hospitalists consider the issues.

Global Surgical Package Period¹

Surgical procedures, categorized as major or minor surgery, are reimbursed for pre-, intra-, and postoperative care. Postoperative care varies according to the procedure’s assigned global period, which designates zero, 10, or 90 postoperative days. (Physicians can review the global period for any given CPT code in the Medicare Physician Fee Schedule, available at www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx.)

Services classified with “XXX” do not have the global period concept. “ZZZ” services denote an “add-on” procedure code that must always be reported with a primary procedure code and assumes the global period assigned to the primary procedure performed.

Major surgery allocates a 90-day global period in which the surgeon is responsible for all related surgical care one day before surgery through 90 postoperative days with no additional charge. Minor surgery, including endoscopy, appoints a zero-day or 10-day postoperative period. The zero-day global period encompasses only services provided on the surgical day, whereas 10-day global periods include services on the surgical day through 10 postoperative days.

Global Surgical Package Components²

The global surgical package comprises a host of responsibilities that include standard facility requirements of filling out all necessary paperwork involved in surgical cases (e.g. preoperative H&P, operative consent forms, preoperative orders). Additionally, the surgeon’s packaged payment includes (at no extra charge):

• Preoperative visits after making the decision for surgery beginning one day prior to surgery;
• All additional postoperative medical or surgical services provided by the surgeon related to complications but not requiring additional trips to the operating room;
• Postoperative visits by the surgeon related to recovery from surgery, including but not limited to dressing changes; local incisional care; removal of cutaneous sutures and staples; line removals; changes and removal of tracheostomy tubes; and discharge services; and
• Postoperative pain management provided by the surgeon.
• Examples of services that are not included in the global surgical package, (i.e. are separately billable and may require an appropriate modifier) are:
• The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery;
• Services of other physicians except where the other physicians are providing coverage for the surgeon or agree on a transfer of care (i.e. a formal agreement in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record);
• Postoperative visits by the surgeon unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery;
• Diagnostic tests and procedures, including diagnostic radiological procedures;
• Clearly distinct surgical procedures during the postoperative period that do not result in repeat operations or treatment for complications;
• Treatment for postoperative complications that requires a return trip to the operating room (OR), catheterization lab or endoscopy suite;
• Immunosuppressive therapy for organ transplants; and
• Critical-care services (CPT codes 99291 and 99292) unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance of the surgeon.

Classification of “Surgeon”

For billing purposes, the “surgeon” is a qualified physician who can perform “surgical” services within their scope of practice. All physicians with the same specialty designation in the same group practice as the “surgeon” (i.e. reporting services under the same tax identification number) are considered a single entity and must adhere to the global period billing rules initiated by the “surgeon.”

Alternately, physicians with different specialty designations in the same group practice (e.g. a hospitalist and a cardiologist in a multispecialty group who report services under the same tax identification number) or different group practices can perform and separately report medically necessary services during the surgeon’s global period, as long as a formal (mutually agreed-upon) transfer of care did not occur.

Medical Necessity

With the growth of HM programs and the admission/attending role expansion, involvement in surgical cases comes under scrutiny for medical necessity. Admitting a patient who has active medical conditions (e.g. hypertension, diabetes, emphysema) is reasonable and necessary because the patient has a well-defined need for medical management by the hospitalist. Participation in the care of these patients is separately billable from the surgeon’s global period package.

Alternatively, a hospitalist might be required to admit and follow surgical patients who have no other identifiable chronic or acute conditions aside from the surgical problem. In these cases, hospitalist involvement may satisfy facility policy (quality of care, risk reduction, etc.) and administrative functions (discharge services or coordination of care) rather than active clinical management. This “medical management” will not be considered “medically necessary” by the payor, and may be denied as incidental to the surgeon’s perioperative services. Erroneous payment can occur, which will result in refund requests, as payors do not want to pay twice for duplicate services. Hospitalists can attempt to negotiate other terms with facilities to account for the unpaid time and effort directed toward these types of cases.

Consider the Case

A patient with numerous medical comorbidities is admitted to the hospitalist service for stabilization prior to surgery, which will occur the next day. The hospitalist can report the appropriate admission code (99221-99223) without need for modifiers because the hospitalist is the attending of record and in a different specialty group. If a private insurer denies the claim as inclusive to the surgical service, the hospitalist can appeal with notes and a cover letter, along with the Medicare guidelines for global surgical package. The hospitalist may continue to provide postoperative daily care, as needed, to manage the patient’s chronic conditions, and report each service as subsequent hospital care (99231-99233) without modifier until the day of discharge (99238-99239). Again, if a payor issues a denial (inclusive to surgery), appealing with notes might be necessary.

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

1. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 40. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. Accessed May 5, 2012.
2. Centers for Medicare & Medicaid Services. ICD-10: HHS proposes one-year delay of ICD-10 compliance date. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/ICD10. Accessed May 5, 2012.
3. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011.

Hospitalists often are involved in the postoperative care of the surgical patient. However, HM is emerging in the admitting/attending role for procedural patients. Confusion can arise as to the nature of the hospitalist service, and whether it is deemed billable. Knowing the surgical package requirements can help hospitalists consider the issues.

Global Surgical Package Period¹

Surgical procedures, categorized as major or minor surgery, are reimbursed for pre-, intra-, and postoperative care. Postoperative care varies according to the procedure’s assigned global period, which designates zero, 10, or 90 postoperative days. (Physicians can review the global period for any given CPT code in the Medicare Physician Fee Schedule, available at www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx.)

Services classified with “XXX” do not have the global period concept. “ZZZ” services denote an “add-on” procedure code that must always be reported with a primary procedure code and assumes the global period assigned to the primary procedure performed.

Major surgery allocates a 90-day global period in which the surgeon is responsible for all related surgical care one day before surgery through 90 postoperative days with no additional charge. Minor surgery, including endoscopy, appoints a zero-day or 10-day postoperative period. The zero-day global period encompasses only services provided on the surgical day, whereas 10-day global periods include services on the surgical day through 10 postoperative days.

Global Surgical Package Components²

The global surgical package comprises a host of responsibilities that include standard facility requirements of filling out all necessary paperwork involved in surgical cases (e.g. preoperative H&P, operative consent forms, preoperative orders). Additionally, the surgeon’s packaged payment includes (at no extra charge):

• Preoperative visits after making the decision for surgery beginning one day prior to surgery;
• All additional postoperative medical or surgical services provided by the surgeon related to complications but not requiring additional trips to the operating room;
• Postoperative visits by the surgeon related to recovery from surgery, including but not limited to dressing changes; local incisional care; removal of cutaneous sutures and staples; line removals; changes and removal of tracheostomy tubes; and discharge services; and
• Postoperative pain management provided by the surgeon.
• Examples of services that are not included in the global surgical package, (i.e. are separately billable and may require an appropriate modifier) are:
• The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery;
• Services of other physicians except where the other physicians are providing coverage for the surgeon or agree on a transfer of care (i.e. a formal agreement in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record);
• Postoperative visits by the surgeon unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery;
• Diagnostic tests and procedures, including diagnostic radiological procedures;
• Clearly distinct surgical procedures during the postoperative period that do not result in repeat operations or treatment for complications;
• Treatment for postoperative complications that requires a return trip to the operating room (OR), catheterization lab or endoscopy suite;
• Immunosuppressive therapy for organ transplants; and
• Critical-care services (CPT codes 99291 and 99292) unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance of the surgeon.

Classification of “Surgeon”

For billing purposes, the “surgeon” is a qualified physician who can perform “surgical” services within their scope of practice. All physicians with the same specialty designation in the same group practice as the “surgeon” (i.e. reporting services under the same tax identification number) are considered a single entity and must adhere to the global period billing rules initiated by the “surgeon.”

Alternately, physicians with different specialty designations in the same group practice (e.g. a hospitalist and a cardiologist in a multispecialty group who report services under the same tax identification number) or different group practices can perform and separately report medically necessary services during the surgeon’s global period, as long as a formal (mutually agreed-upon) transfer of care did not occur.

Medical Necessity

With the growth of HM programs and the admission/attending role expansion, involvement in surgical cases comes under scrutiny for medical necessity. Admitting a patient who has active medical conditions (e.g. hypertension, diabetes, emphysema) is reasonable and necessary because the patient has a well-defined need for medical management by the hospitalist. Participation in the care of these patients is separately billable from the surgeon’s global period package.

Alternatively, a hospitalist might be required to admit and follow surgical patients who have no other identifiable chronic or acute conditions aside from the surgical problem. In these cases, hospitalist involvement may satisfy facility policy (quality of care, risk reduction, etc.) and administrative functions (discharge services or coordination of care) rather than active clinical management. This “medical management” will not be considered “medically necessary” by the payor, and may be denied as incidental to the surgeon’s perioperative services. Erroneous payment can occur, which will result in refund requests, as payors do not want to pay twice for duplicate services. Hospitalists can attempt to negotiate other terms with facilities to account for the unpaid time and effort directed toward these types of cases.

Consider the Case

A patient with numerous medical comorbidities is admitted to the hospitalist service for stabilization prior to surgery, which will occur the next day. The hospitalist can report the appropriate admission code (99221-99223) without need for modifiers because the hospitalist is the attending of record and in a different specialty group. If a private insurer denies the claim as inclusive to the surgical service, the hospitalist can appeal with notes and a cover letter, along with the Medicare guidelines for global surgical package. The hospitalist may continue to provide postoperative daily care, as needed, to manage the patient’s chronic conditions, and report each service as subsequent hospital care (99231-99233) without modifier until the day of discharge (99238-99239). Again, if a payor issues a denial (inclusive to surgery), appealing with notes might be necessary.

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

1. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 40. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf. Accessed May 5, 2012.
2. Centers for Medicare & Medicaid Services. ICD-10: HHS proposes one-year delay of ICD-10 compliance date. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/ICD10. Accessed May 5, 2012.
3. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011.

PRO

A powerful tool, subspecialty certification should be adopted—and soon

There are many different ways for pediatric hospital medicine to evolve and gain recognition. Board certification with required fellowship training is the most well-known method. For adult hospitalists, recognition of Focused Practice in Hospital Medicine (FPHM) has been established. Residency programs are becoming more innovative, creating additional tracks to provide accelerated fellowship education. What path should be chosen for the future of pediatric hospital medicine?

The decision could be compared to purchasing a cellphone. Simple flip phones are sufficient for making phone calls, just as a graduating pediatrics resident might care for routine inpatients. But the smartphone, like the fellowship/subspecialty certification route, provides advantages that could be worth the additional costs.

You can tell a lot about a person by looking at their cellphone. It often reveals personality traits, professions, and behavioral tendencies. Similarly, administrators, colleagues, and other payors might make assumptions based on fellowship/subspecialty certification status. Pediatric hospitalists should be considered experts in the field of clinical HM, hospital-based research, quality improvement (QI), inpatient procedures, and administrative leadership. Fellowship directors have begun discussing how to standardize these content areas. Subspecialty certification after such training will provide a powerful tool for hospitalists to navigate potentially complex clinical scenarios, hospital bureaucracies and/or academic hierarchies. Fellowship training will add a more concrete identity and standards of quality to our subspecialty.

Smartphones are “smart” because they bring convenience and efficiency. The same can be said about fellowship training. Residency training no longer addresses all the needs of a practicing hospitalist. Although one can attend workshops on QI or research and learn hospital administration, all while on the job, many young hospitalists struggle to adapt quickly early in their career; they might fail to thrive. Fellowship programs would provide a learner-centered environment and protected time to accomplish these goals. Certification would help ensure that trainees have the knowledge and competencies needed for the job. This process, designed to create a well-prepared hospitalist work force, should lead to better advancement within the field, which would mean more hospitalists in meaningful leadership roles and improved quality of hospital care.

The cost of a cellphone and its monthly plan must be taken into account when choosing what purchase. Similarly, the benefits of additional education and recognition must be measured against the costs of additional training. For most, the benefits of well-trained hospitalists outweigh the costs in the long run. Concerns of alienating those without board certification or limiting the work force likely are unfounded. The majority of EDs are staffed by general emergency medicine physicians who do not have pediatric emergency medicine certification—and they all see children, and provide referrals to dedicated children’s facilities when needed. Similarly, community hospital wards can choose to follow suit, depending on their needs.

Fellowship training and subspecialty board certification offer numerous benefits that likely outweigh the costs of a new “plan.” We don’t want just anyone on call; we want a future full of smart hospitalists who are leading practitioners of QI, education, and scholarship.

Dr. Chen is assistant professor in the department of pediatrics at the University of Texas Southwestern in Dallas.

CON

One-size-fits-all approach is not what pediatric hospitalists need

According to Freed et al in the Journal of Hospital Medicine, the central goals of a fellowship in pediatric HM include “advanced training in the clinical care of hospitalized patients, quality improvement (QI), and hospital administration.”¹ To determine if certification within pediatric hospital medicine should require a fellowship, it is necessary to decide if there are additional skills beyond those obtained during a pediatric residency that are required for practice as a pediatric hospitalist.

Pediatric residencies are designed to provide residents with the skills to practice in the field of general pediatrics. According to Accreditation Council for Graduate Medical Education (ACGME) standards, just 40% of a resident’s training is required to be in the outpatient setting. There is the expectation that at the end of three years, a resident is capable of spending 95% of their practice in the primary-care setting despite spending less than half of their training in outpatient medicine.

Having a greater focus on inpatient medicine during residency provides a knowledge base that is adequate to start an HM career. As intended, the amount of training dedicated to inpatient and outpatient care in a pediatric residency program is adequate to achieve the skills that make them capable of practicing both inpatient and outpatient care.

Although Freed stated the goal of advanced training, it is unclear what specialized body of knowledge would be gained during a fellowship. The need for advanced clinical training is a concept that is a careerlong, neverending endeavor. Even if this were the reason to require a fellowship, how long is long enough to have mastered clinical care?

One year? Two years? 35 years? If more than half of a three-year residency is not enough time to provide residents the education and training to care for hospitalized inpatients, we should not require more training; we should fix our current training system.

Administrative experience and training in QI and research are important skills that can help advance a hospitalist’s career. It is important to recognize that because these skills are not required for all pediatric hospitalist positions, it would be unnecessary for all hospitalists to attain these skills in a fellowship. In addition, for those interested in administration or research, there are many other ways to attain those skills, including the APA educational scholars program or obtaining a master’s degree in medical education. The added benefit of these avenues for additional skills is that they can be completed throughout a career as a pediatric hospitalist.

As pediatric hospital medicine is a field in its early stages, it is important to consider all options for certification. While fellowship training has been the path for many subspecialties within pediatrics, HM will be better served by recognizing the need to remain inclusive. The positions within HM are broad, and the training should be individualized for the skills each physician requires.

Dr. Eagle is a hospitalist in the general medicine service at The Joseph M. Sanzari Children’s Hospital at Hackensack University Medical Center in New Jersey.

Reference

1. Freed G, Dunham K. Characteristics of pediatric hospital medicine fellowships and training programs. J Hosp Med. 2009;4(3):157-163.

PRO

A powerful tool, subspecialty certification should be adopted—and soon

There are many different ways for pediatric hospital medicine to evolve and gain recognition. Board certification with required fellowship training is the most well-known method. For adult hospitalists, recognition of Focused Practice in Hospital Medicine (FPHM) has been established. Residency programs are becoming more innovative, creating additional tracks to provide accelerated fellowship education. What path should be chosen for the future of pediatric hospital medicine?

The decision could be compared to purchasing a cellphone. Simple flip phones are sufficient for making phone calls, just as a graduating pediatrics resident might care for routine inpatients. But the smartphone, like the fellowship/subspecialty certification route, provides advantages that could be worth the additional costs.

You can tell a lot about a person by looking at their cellphone. It often reveals personality traits, professions, and behavioral tendencies. Similarly, administrators, colleagues, and other payors might make assumptions based on fellowship/subspecialty certification status. Pediatric hospitalists should be considered experts in the field of clinical HM, hospital-based research, quality improvement (QI), inpatient procedures, and administrative leadership. Fellowship directors have begun discussing how to standardize these content areas. Subspecialty certification after such training will provide a powerful tool for hospitalists to navigate potentially complex clinical scenarios, hospital bureaucracies and/or academic hierarchies. Fellowship training will add a more concrete identity and standards of quality to our subspecialty.

Smartphones are “smart” because they bring convenience and efficiency. The same can be said about fellowship training. Residency training no longer addresses all the needs of a practicing hospitalist. Although one can attend workshops on QI or research and learn hospital administration, all while on the job, many young hospitalists struggle to adapt quickly early in their career; they might fail to thrive. Fellowship programs would provide a learner-centered environment and protected time to accomplish these goals. Certification would help ensure that trainees have the knowledge and competencies needed for the job. This process, designed to create a well-prepared hospitalist work force, should lead to better advancement within the field, which would mean more hospitalists in meaningful leadership roles and improved quality of hospital care.

The cost of a cellphone and its monthly plan must be taken into account when choosing what purchase. Similarly, the benefits of additional education and recognition must be measured against the costs of additional training. For most, the benefits of well-trained hospitalists outweigh the costs in the long run. Concerns of alienating those without board certification or limiting the work force likely are unfounded. The majority of EDs are staffed by general emergency medicine physicians who do not have pediatric emergency medicine certification—and they all see children, and provide referrals to dedicated children’s facilities when needed. Similarly, community hospital wards can choose to follow suit, depending on their needs.

Fellowship training and subspecialty board certification offer numerous benefits that likely outweigh the costs of a new “plan.” We don’t want just anyone on call; we want a future full of smart hospitalists who are leading practitioners of QI, education, and scholarship.

Dr. Chen is assistant professor in the department of pediatrics at the University of Texas Southwestern in Dallas.

CON

One-size-fits-all approach is not what pediatric hospitalists need

According to Freed et al in the Journal of Hospital Medicine, the central goals of a fellowship in pediatric HM include “advanced training in the clinical care of hospitalized patients, quality improvement (QI), and hospital administration.”¹ To determine if certification within pediatric hospital medicine should require a fellowship, it is necessary to decide if there are additional skills beyond those obtained during a pediatric residency that are required for practice as a pediatric hospitalist.

Pediatric residencies are designed to provide residents with the skills to practice in the field of general pediatrics. According to Accreditation Council for Graduate Medical Education (ACGME) standards, just 40% of a resident’s training is required to be in the outpatient setting. There is the expectation that at the end of three years, a resident is capable of spending 95% of their practice in the primary-care setting despite spending less than half of their training in outpatient medicine.

Having a greater focus on inpatient medicine during residency provides a knowledge base that is adequate to start an HM career. As intended, the amount of training dedicated to inpatient and outpatient care in a pediatric residency program is adequate to achieve the skills that make them capable of practicing both inpatient and outpatient care.

Although Freed stated the goal of advanced training, it is unclear what specialized body of knowledge would be gained during a fellowship. The need for advanced clinical training is a concept that is a careerlong, neverending endeavor. Even if this were the reason to require a fellowship, how long is long enough to have mastered clinical care?

One year? Two years? 35 years? If more than half of a three-year residency is not enough time to provide residents the education and training to care for hospitalized inpatients, we should not require more training; we should fix our current training system.

Administrative experience and training in QI and research are important skills that can help advance a hospitalist’s career. It is important to recognize that because these skills are not required for all pediatric hospitalist positions, it would be unnecessary for all hospitalists to attain these skills in a fellowship. In addition, for those interested in administration or research, there are many other ways to attain those skills, including the APA educational scholars program or obtaining a master’s degree in medical education. The added benefit of these avenues for additional skills is that they can be completed throughout a career as a pediatric hospitalist.

As pediatric hospital medicine is a field in its early stages, it is important to consider all options for certification. While fellowship training has been the path for many subspecialties within pediatrics, HM will be better served by recognizing the need to remain inclusive. The positions within HM are broad, and the training should be individualized for the skills each physician requires.

Dr. Eagle is a hospitalist in the general medicine service at The Joseph M. Sanzari Children’s Hospital at Hackensack University Medical Center in New Jersey.

Reference

1. Freed G, Dunham K. Characteristics of pediatric hospital medicine fellowships and training programs. J Hosp Med. 2009;4(3):157-163.

PRO

A powerful tool, subspecialty certification should be adopted—and soon

There are many different ways for pediatric hospital medicine to evolve and gain recognition. Board certification with required fellowship training is the most well-known method. For adult hospitalists, recognition of Focused Practice in Hospital Medicine (FPHM) has been established. Residency programs are becoming more innovative, creating additional tracks to provide accelerated fellowship education. What path should be chosen for the future of pediatric hospital medicine?

The decision could be compared to purchasing a cellphone. Simple flip phones are sufficient for making phone calls, just as a graduating pediatrics resident might care for routine inpatients. But the smartphone, like the fellowship/subspecialty certification route, provides advantages that could be worth the additional costs.

You can tell a lot about a person by looking at their cellphone. It often reveals personality traits, professions, and behavioral tendencies. Similarly, administrators, colleagues, and other payors might make assumptions based on fellowship/subspecialty certification status. Pediatric hospitalists should be considered experts in the field of clinical HM, hospital-based research, quality improvement (QI), inpatient procedures, and administrative leadership. Fellowship directors have begun discussing how to standardize these content areas. Subspecialty certification after such training will provide a powerful tool for hospitalists to navigate potentially complex clinical scenarios, hospital bureaucracies and/or academic hierarchies. Fellowship training will add a more concrete identity and standards of quality to our subspecialty.

Smartphones are “smart” because they bring convenience and efficiency. The same can be said about fellowship training. Residency training no longer addresses all the needs of a practicing hospitalist. Although one can attend workshops on QI or research and learn hospital administration, all while on the job, many young hospitalists struggle to adapt quickly early in their career; they might fail to thrive. Fellowship programs would provide a learner-centered environment and protected time to accomplish these goals. Certification would help ensure that trainees have the knowledge and competencies needed for the job. This process, designed to create a well-prepared hospitalist work force, should lead to better advancement within the field, which would mean more hospitalists in meaningful leadership roles and improved quality of hospital care.

The cost of a cellphone and its monthly plan must be taken into account when choosing what purchase. Similarly, the benefits of additional education and recognition must be measured against the costs of additional training. For most, the benefits of well-trained hospitalists outweigh the costs in the long run. Concerns of alienating those without board certification or limiting the work force likely are unfounded. The majority of EDs are staffed by general emergency medicine physicians who do not have pediatric emergency medicine certification—and they all see children, and provide referrals to dedicated children’s facilities when needed. Similarly, community hospital wards can choose to follow suit, depending on their needs.

Fellowship training and subspecialty board certification offer numerous benefits that likely outweigh the costs of a new “plan.” We don’t want just anyone on call; we want a future full of smart hospitalists who are leading practitioners of QI, education, and scholarship.

Dr. Chen is assistant professor in the department of pediatrics at the University of Texas Southwestern in Dallas.

CON

One-size-fits-all approach is not what pediatric hospitalists need

According to Freed et al in the Journal of Hospital Medicine, the central goals of a fellowship in pediatric HM include “advanced training in the clinical care of hospitalized patients, quality improvement (QI), and hospital administration.”¹ To determine if certification within pediatric hospital medicine should require a fellowship, it is necessary to decide if there are additional skills beyond those obtained during a pediatric residency that are required for practice as a pediatric hospitalist.

Pediatric residencies are designed to provide residents with the skills to practice in the field of general pediatrics. According to Accreditation Council for Graduate Medical Education (ACGME) standards, just 40% of a resident’s training is required to be in the outpatient setting. There is the expectation that at the end of three years, a resident is capable of spending 95% of their practice in the primary-care setting despite spending less than half of their training in outpatient medicine.

Having a greater focus on inpatient medicine during residency provides a knowledge base that is adequate to start an HM career. As intended, the amount of training dedicated to inpatient and outpatient care in a pediatric residency program is adequate to achieve the skills that make them capable of practicing both inpatient and outpatient care.

Although Freed stated the goal of advanced training, it is unclear what specialized body of knowledge would be gained during a fellowship. The need for advanced clinical training is a concept that is a careerlong, neverending endeavor. Even if this were the reason to require a fellowship, how long is long enough to have mastered clinical care?

One year? Two years? 35 years? If more than half of a three-year residency is not enough time to provide residents the education and training to care for hospitalized inpatients, we should not require more training; we should fix our current training system.

Administrative experience and training in QI and research are important skills that can help advance a hospitalist’s career. It is important to recognize that because these skills are not required for all pediatric hospitalist positions, it would be unnecessary for all hospitalists to attain these skills in a fellowship. In addition, for those interested in administration or research, there are many other ways to attain those skills, including the APA educational scholars program or obtaining a master’s degree in medical education. The added benefit of these avenues for additional skills is that they can be completed throughout a career as a pediatric hospitalist.

As pediatric hospital medicine is a field in its early stages, it is important to consider all options for certification. While fellowship training has been the path for many subspecialties within pediatrics, HM will be better served by recognizing the need to remain inclusive. The positions within HM are broad, and the training should be individualized for the skills each physician requires.

Dr. Eagle is a hospitalist in the general medicine service at The Joseph M. Sanzari Children’s Hospital at Hackensack University Medical Center in New Jersey.

Reference

1. Freed G, Dunham K. Characteristics of pediatric hospital medicine fellowships and training programs. J Hosp Med. 2009;4(3):157-163.

New technology that infuses a copper oxide into hard surfaces or fabrics in order to boost infection control could soon become a major weapon in hospitals, according to the CEOs of two Virginia companies now developing such technologies.

Cupron (http://www.cupron.com/), based in Richmond, Va., provides the infusion of a proprietary copper oxide compound into such hard surfaces as flooring, countertops, building components, and furniture, and into fabrics such as gowns, uniforms, and linens, says company chairman Paul Rocheleau. Cupron is partnering with EOS Surfaces (http://eos-surfaces.com/cupron/), based in Portsmouth, Va., a developer of solid countertop surfaces, which company president Ken Trinder says are thicker than comparable building products.

Together, the companies are seeking approval from the U.S. Environmental Protection Agency to market these products with registrations for their public health claims of preventing hospital-acquired infections (HAIs) caused by bacteria, fungi, and viruses. The products recently were tested against Staphylococcus and Enterobacter bacteria, with 99.9% effectiveness in killing organisms, Rocheleau says.

“It is well known that copper has the ability to kill pathogens,” he adds. “What’s new are the methods to deliver that technology.”

He calls the copper-ion technology an additional layer of infection control, meant not to supplant other hospital protocols but to become part of overall risk-management programs to control HAIs. Other Cupron products, such as anti-odor footwear, are already on the market, but EOS aims to market the hard-surface products to health facilities starting in the second half of this year. “We’re also well advanced on the first of several clinical studies of the impact of Cupron-infused textiles and hard surfaces on infection rates,” Rocheleau says.

Meanwhile, a new “intelligent handwash monitoring system” to promote hand hygiene compliance in order to prevent HAIs that is now being tested in the United Kingdom by the global thermal technology company Irisys (www.irisys.co.uk/) was presented at the Association for Professionals in Infection Control and Epidemiology 2012 conference in June in San Antonio.

It uses non-intrusive therapy sensors deployed throughout healthcare facilities to detect people’s movements and determine accurate counts of handwashing opportunities, which are then compared to actual handwashing (or sanitizing gel) occurrences. The intention is to promote greater compliance with infection-preventing hand hygiene without violating personal privacy, such as through the use of video surveillance.

New technology that infuses a copper oxide into hard surfaces or fabrics in order to boost infection control could soon become a major weapon in hospitals, according to the CEOs of two Virginia companies now developing such technologies.

Cupron (http://www.cupron.com/), based in Richmond, Va., provides the infusion of a proprietary copper oxide compound into such hard surfaces as flooring, countertops, building components, and furniture, and into fabrics such as gowns, uniforms, and linens, says company chairman Paul Rocheleau. Cupron is partnering with EOS Surfaces (http://eos-surfaces.com/cupron/), based in Portsmouth, Va., a developer of solid countertop surfaces, which company president Ken Trinder says are thicker than comparable building products.

Together, the companies are seeking approval from the U.S. Environmental Protection Agency to market these products with registrations for their public health claims of preventing hospital-acquired infections (HAIs) caused by bacteria, fungi, and viruses. The products recently were tested against Staphylococcus and Enterobacter bacteria, with 99.9% effectiveness in killing organisms, Rocheleau says.

“It is well known that copper has the ability to kill pathogens,” he adds. “What’s new are the methods to deliver that technology.”

He calls the copper-ion technology an additional layer of infection control, meant not to supplant other hospital protocols but to become part of overall risk-management programs to control HAIs. Other Cupron products, such as anti-odor footwear, are already on the market, but EOS aims to market the hard-surface products to health facilities starting in the second half of this year. “We’re also well advanced on the first of several clinical studies of the impact of Cupron-infused textiles and hard surfaces on infection rates,” Rocheleau says.

Meanwhile, a new “intelligent handwash monitoring system” to promote hand hygiene compliance in order to prevent HAIs that is now being tested in the United Kingdom by the global thermal technology company Irisys (www.irisys.co.uk/) was presented at the Association for Professionals in Infection Control and Epidemiology 2012 conference in June in San Antonio.

It uses non-intrusive therapy sensors deployed throughout healthcare facilities to detect people’s movements and determine accurate counts of handwashing opportunities, which are then compared to actual handwashing (or sanitizing gel) occurrences. The intention is to promote greater compliance with infection-preventing hand hygiene without violating personal privacy, such as through the use of video surveillance.

New technology that infuses a copper oxide into hard surfaces or fabrics in order to boost infection control could soon become a major weapon in hospitals, according to the CEOs of two Virginia companies now developing such technologies.

Cupron (http://www.cupron.com/), based in Richmond, Va., provides the infusion of a proprietary copper oxide compound into such hard surfaces as flooring, countertops, building components, and furniture, and into fabrics such as gowns, uniforms, and linens, says company chairman Paul Rocheleau. Cupron is partnering with EOS Surfaces (http://eos-surfaces.com/cupron/), based in Portsmouth, Va., a developer of solid countertop surfaces, which company president Ken Trinder says are thicker than comparable building products.

Together, the companies are seeking approval from the U.S. Environmental Protection Agency to market these products with registrations for their public health claims of preventing hospital-acquired infections (HAIs) caused by bacteria, fungi, and viruses. The products recently were tested against Staphylococcus and Enterobacter bacteria, with 99.9% effectiveness in killing organisms, Rocheleau says.

“It is well known that copper has the ability to kill pathogens,” he adds. “What’s new are the methods to deliver that technology.”

He calls the copper-ion technology an additional layer of infection control, meant not to supplant other hospital protocols but to become part of overall risk-management programs to control HAIs. Other Cupron products, such as anti-odor footwear, are already on the market, but EOS aims to market the hard-surface products to health facilities starting in the second half of this year. “We’re also well advanced on the first of several clinical studies of the impact of Cupron-infused textiles and hard surfaces on infection rates,” Rocheleau says.

Meanwhile, a new “intelligent handwash monitoring system” to promote hand hygiene compliance in order to prevent HAIs that is now being tested in the United Kingdom by the global thermal technology company Irisys (www.irisys.co.uk/) was presented at the Association for Professionals in Infection Control and Epidemiology 2012 conference in June in San Antonio.

It uses non-intrusive therapy sensors deployed throughout healthcare facilities to detect people’s movements and determine accurate counts of handwashing opportunities, which are then compared to actual handwashing (or sanitizing gel) occurrences. The intention is to promote greater compliance with infection-preventing hand hygiene without violating personal privacy, such as through the use of video surveillance.

A new study in the Journal of the American Medical Informatics Association offers demographic predictors of physicians and their usage of web-based communication technologies.¹ Younger, male doctors who have privileges at a teaching hospital were better predictors of the use of various technologies during the previous six months than were practice-based characteristics, such as specialty, setting, years in practice, or number of patients treated. Communication strategies tallied included using portable devices to access the Internet, visiting social networking websites, communicating by email with patients, listening to podcasts, or writing blog posts.

Lead author Crystale Purvis Cooper, PhD, a researcher at the Soltera Center for Cancer Prevention and Control in Tucson, Ariz., and colleagues drew upon 2009 data from 1,750 physicians in DocStyles, an annual survey of physicians and other health professionals conducted by communications firm Porter Novelli.

References

1. Cooper CP, Gelb CA, Rim SH, Hawkins NA, Rodriguez JL, Polonec L. Physicians who use social media and other internet-based communication technologies. J Am Med Inform Assoc. 2012 May 25 [Epub ahead of print].

A new study in the Journal of the American Medical Informatics Association offers demographic predictors of physicians and their usage of web-based communication technologies.¹ Younger, male doctors who have privileges at a teaching hospital were better predictors of the use of various technologies during the previous six months than were practice-based characteristics, such as specialty, setting, years in practice, or number of patients treated. Communication strategies tallied included using portable devices to access the Internet, visiting social networking websites, communicating by email with patients, listening to podcasts, or writing blog posts.

Lead author Crystale Purvis Cooper, PhD, a researcher at the Soltera Center for Cancer Prevention and Control in Tucson, Ariz., and colleagues drew upon 2009 data from 1,750 physicians in DocStyles, an annual survey of physicians and other health professionals conducted by communications firm Porter Novelli.

References

1. Cooper CP, Gelb CA, Rim SH, Hawkins NA, Rodriguez JL, Polonec L. Physicians who use social media and other internet-based communication technologies. J Am Med Inform Assoc. 2012 May 25 [Epub ahead of print].

A new study in the Journal of the American Medical Informatics Association offers demographic predictors of physicians and their usage of web-based communication technologies.¹ Younger, male doctors who have privileges at a teaching hospital were better predictors of the use of various technologies during the previous six months than were practice-based characteristics, such as specialty, setting, years in practice, or number of patients treated. Communication strategies tallied included using portable devices to access the Internet, visiting social networking websites, communicating by email with patients, listening to podcasts, or writing blog posts.

Lead author Crystale Purvis Cooper, PhD, a researcher at the Soltera Center for Cancer Prevention and Control in Tucson, Ariz., and colleagues drew upon 2009 data from 1,750 physicians in DocStyles, an annual survey of physicians and other health professionals conducted by communications firm Porter Novelli.

References

1. Cooper CP, Gelb CA, Rim SH, Hawkins NA, Rodriguez JL, Polonec L. Physicians who use social media and other internet-based communication technologies. J Am Med Inform Assoc. 2012 May 25 [Epub ahead of print].

Average annual number of hospitalized adult patients with a venous thromboembolism (VTE) during 2007 to 2009.

A total of 348,558 hospitalized patients had deep vein thromboses, 277,549 had pulmonary embolisms, and 78,511 had both, according to estimates compiled for the federal Centers for Disease Control and Prevention (CDC).¹ Of those patients with hospital VTEs, 28,726 die each year. The risk for VTE is known to be elevated in hospitalized patients due to major surgery, immobility, or comorbid conditions. Although it can often be prevented through appropriate administration of prophylaxis—either pharmacologic agents or mechanical devices—

CDC notes that “current use of prophylaxis in hospitalized patients might be suboptimal.”

Reference

1. Centers for Disease Control and Prevention. Venous thromboembolism in adult hospitalizations—United States, 2007-2009. MMWR Morb Mortal Wkly Rep. 2012;61:401-404.

Average annual number of hospitalized adult patients with a venous thromboembolism (VTE) during 2007 to 2009.

A total of 348,558 hospitalized patients had deep vein thromboses, 277,549 had pulmonary embolisms, and 78,511 had both, according to estimates compiled for the federal Centers for Disease Control and Prevention (CDC).¹ Of those patients with hospital VTEs, 28,726 die each year. The risk for VTE is known to be elevated in hospitalized patients due to major surgery, immobility, or comorbid conditions. Although it can often be prevented through appropriate administration of prophylaxis—either pharmacologic agents or mechanical devices—

CDC notes that “current use of prophylaxis in hospitalized patients might be suboptimal.”

Reference

1. Centers for Disease Control and Prevention. Venous thromboembolism in adult hospitalizations—United States, 2007-2009. MMWR Morb Mortal Wkly Rep. 2012;61:401-404.

Average annual number of hospitalized adult patients with a venous thromboembolism (VTE) during 2007 to 2009.

A total of 348,558 hospitalized patients had deep vein thromboses, 277,549 had pulmonary embolisms, and 78,511 had both, according to estimates compiled for the federal Centers for Disease Control and Prevention (CDC).¹ Of those patients with hospital VTEs, 28,726 die each year. The risk for VTE is known to be elevated in hospitalized patients due to major surgery, immobility, or comorbid conditions. Although it can often be prevented through appropriate administration of prophylaxis—either pharmacologic agents or mechanical devices—

CDC notes that “current use of prophylaxis in hospitalized patients might be suboptimal.”

Reference

1. Centers for Disease Control and Prevention. Venous thromboembolism in adult hospitalizations—United States, 2007-2009. MMWR Morb Mortal Wkly Rep. 2012;61:401-404.

A hospital observation unit run by hospitalists rather than the more typical model led by ED physicians can be financially viable, suggests an abstract presented at HM12 in April in San Diego. One such unit generated $915,000 in facility fee charges, and during a three-month audit posted net revenue of $49,000; the unit also reduced patients’ length of stay (LOS) on observation status by 25%, according to lead author Mary Maher, MD, a hospitalist at Denver Health Medical Center.¹

Previously, Denver Health’s ED had informally operated a small observation unit, primarily for patients with such diagnoses as low-risk chest pain. But due to increasing numbers of observation admissions and the need to manage their flow through the typically full safety-net teaching hospital, the hospitalist department was asked in 2011 to develop a new, hospitalist-run unit, Dr. Maher explains.

In its first six months of operation, the five-bed observation unit cared for 648 patients, with 12% admitted to the hospital. A single hospitalist and mid-level practitioner cover each shift, with additional responsibilities for managing patient flow and new hospital admissions. Dr. Maher says specialized nursing staffers are now familiar with the hospital’s admission criteria and care pathways for common diagnoses. A typical observation patient has chest pain and a history of coronary artery disease but negative clinical markers. Other common diagnoses, with established clinical pathways and discharge criteria, include asthma, syncope, COPD, and gastrointestinal illness.

“Hospitalists are primed to take care of patients who are in this observation status,” Dr. Maher says. “They are a little more complex than patients typically seen in emergency department units. The challenge for hospitalists is to understand the hospital’s admission guidelines and to work collaboratively with utilization management staff.”

Denver Health uses the Milliman Care Guidelines to guide inpatient admissions, but these can be difficult to translate into clinical practice and require some study by physicians, she adds.² For more information about the poster and the unit, email [email protected].

References

1. Maher M, Mascolo M, Mancini D, et al. Creation of a financially viable hospitalist-run observation unit in a safety net hospital. Paper presented at Hospital Medicine 2012, April 1-4, 2012, San Diego.
2. Milliman Inc. Milliman Care Guidelines. Milliman Inc. website. Available at: http://www.milliman.com/expertise/healthcare/products-tools/milliman-care-guidelines/. Accessed July 8, 2012.

A hospital observation unit run by hospitalists rather than the more typical model led by ED physicians can be financially viable, suggests an abstract presented at HM12 in April in San Diego. One such unit generated $915,000 in facility fee charges, and during a three-month audit posted net revenue of $49,000; the unit also reduced patients’ length of stay (LOS) on observation status by 25%, according to lead author Mary Maher, MD, a hospitalist at Denver Health Medical Center.¹

Previously, Denver Health’s ED had informally operated a small observation unit, primarily for patients with such diagnoses as low-risk chest pain. But due to increasing numbers of observation admissions and the need to manage their flow through the typically full safety-net teaching hospital, the hospitalist department was asked in 2011 to develop a new, hospitalist-run unit, Dr. Maher explains.

In its first six months of operation, the five-bed observation unit cared for 648 patients, with 12% admitted to the hospital. A single hospitalist and mid-level practitioner cover each shift, with additional responsibilities for managing patient flow and new hospital admissions. Dr. Maher says specialized nursing staffers are now familiar with the hospital’s admission criteria and care pathways for common diagnoses. A typical observation patient has chest pain and a history of coronary artery disease but negative clinical markers. Other common diagnoses, with established clinical pathways and discharge criteria, include asthma, syncope, COPD, and gastrointestinal illness.

“Hospitalists are primed to take care of patients who are in this observation status,” Dr. Maher says. “They are a little more complex than patients typically seen in emergency department units. The challenge for hospitalists is to understand the hospital’s admission guidelines and to work collaboratively with utilization management staff.”

Denver Health uses the Milliman Care Guidelines to guide inpatient admissions, but these can be difficult to translate into clinical practice and require some study by physicians, she adds.² For more information about the poster and the unit, email [email protected].

References

1. Maher M, Mascolo M, Mancini D, et al. Creation of a financially viable hospitalist-run observation unit in a safety net hospital. Paper presented at Hospital Medicine 2012, April 1-4, 2012, San Diego.
2. Milliman Inc. Milliman Care Guidelines. Milliman Inc. website. Available at: http://www.milliman.com/expertise/healthcare/products-tools/milliman-care-guidelines/. Accessed July 8, 2012.

A hospital observation unit run by hospitalists rather than the more typical model led by ED physicians can be financially viable, suggests an abstract presented at HM12 in April in San Diego. One such unit generated $915,000 in facility fee charges, and during a three-month audit posted net revenue of $49,000; the unit also reduced patients’ length of stay (LOS) on observation status by 25%, according to lead author Mary Maher, MD, a hospitalist at Denver Health Medical Center.¹

Previously, Denver Health’s ED had informally operated a small observation unit, primarily for patients with such diagnoses as low-risk chest pain. But due to increasing numbers of observation admissions and the need to manage their flow through the typically full safety-net teaching hospital, the hospitalist department was asked in 2011 to develop a new, hospitalist-run unit, Dr. Maher explains.

In its first six months of operation, the five-bed observation unit cared for 648 patients, with 12% admitted to the hospital. A single hospitalist and mid-level practitioner cover each shift, with additional responsibilities for managing patient flow and new hospital admissions. Dr. Maher says specialized nursing staffers are now familiar with the hospital’s admission criteria and care pathways for common diagnoses. A typical observation patient has chest pain and a history of coronary artery disease but negative clinical markers. Other common diagnoses, with established clinical pathways and discharge criteria, include asthma, syncope, COPD, and gastrointestinal illness.

“Hospitalists are primed to take care of patients who are in this observation status,” Dr. Maher says. “They are a little more complex than patients typically seen in emergency department units. The challenge for hospitalists is to understand the hospital’s admission guidelines and to work collaboratively with utilization management staff.”

Denver Health uses the Milliman Care Guidelines to guide inpatient admissions, but these can be difficult to translate into clinical practice and require some study by physicians, she adds.² For more information about the poster and the unit, email [email protected].

References

1. Maher M, Mascolo M, Mancini D, et al. Creation of a financially viable hospitalist-run observation unit in a safety net hospital. Paper presented at Hospital Medicine 2012, April 1-4, 2012, San Diego.
2. Milliman Inc. Milliman Care Guidelines. Milliman Inc. website. Available at: http://www.milliman.com/expertise/healthcare/products-tools/milliman-care-guidelines/. Accessed July 8, 2012.

The most recent report on hospital quality issued by independent healthcare rating company HealthGrades estimates that 254,000 safety incidents that occurred in U.S. hospitals from 2008 to 2010 could have been prevented, and that 56,367 hospitalized patients who died experienced one or more of those preventable events.¹

Drawing upon consumer-reported quality data in CMS’ Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, HealthGrades concluded that 15% more patient safety incidents occurred at hospitals who ranked lowest (the bottom 10%) on the quality of their physician communication.

Reference

1. CPM Healthgrades. Patient safety and satisfaction: the state of American hospitals. CPM Healthgrades website. Available at: https://www.cpm.com/CPM/assets/File/HealthGradesPatientSafetySatisfactionReport2012.pdf. Accessed July 8, 2012.

The most recent report on hospital quality issued by independent healthcare rating company HealthGrades estimates that 254,000 safety incidents that occurred in U.S. hospitals from 2008 to 2010 could have been prevented, and that 56,367 hospitalized patients who died experienced one or more of those preventable events.¹

Drawing upon consumer-reported quality data in CMS’ Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, HealthGrades concluded that 15% more patient safety incidents occurred at hospitals who ranked lowest (the bottom 10%) on the quality of their physician communication.

Reference

1. CPM Healthgrades. Patient safety and satisfaction: the state of American hospitals. CPM Healthgrades website. Available at: https://www.cpm.com/CPM/assets/File/HealthGradesPatientSafetySatisfactionReport2012.pdf. Accessed July 8, 2012.

The most recent report on hospital quality issued by independent healthcare rating company HealthGrades estimates that 254,000 safety incidents that occurred in U.S. hospitals from 2008 to 2010 could have been prevented, and that 56,367 hospitalized patients who died experienced one or more of those preventable events.¹

Drawing upon consumer-reported quality data in CMS’ Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, HealthGrades concluded that 15% more patient safety incidents occurred at hospitals who ranked lowest (the bottom 10%) on the quality of their physician communication.

Reference

1. CPM Healthgrades. Patient safety and satisfaction: the state of American hospitals. CPM Healthgrades website. Available at: https://www.cpm.com/CPM/assets/File/HealthGradesPatientSafetySatisfactionReport2012.pdf. Accessed July 8, 2012.

EDITOR’S NOTE: An incorrect version of Win Whitcomb’s “On the Horizon” column was published in the July issue of The Hospitalist. We deeply regret the error. The correct version of Dr. Whitcomb’s column appears this month, with proper attribution given to hospitalist Brad Flansbaum, DO, SFHM, who contributed to the column.

Assigning the appropriate status to patients (“inpatient” or “observation”) has emerged as a front-and-center issue for hospitalists. Also known as “medical necessity,” many HM groups have been called upon to help solve the “status” problem for their institutions. With nearly 1 in 5 hospitalized patients on observation status in U.S. hospitals, appropriately assigning status is now a dominant, system-level challenge for hospitalists.

This month, we asked two experts to shed light on the nature of this beast, with a focus on the impact on the patient. Brad Flansbaum, DO, SFHM, hospitalist at Lenox Hill Hospital in New York City, and Patrick Conway, MD, FAAP, MSC, SFHM, chief medical officer at the Centers for Medicare & Medicaid Services (CMS), were kind enough to participate in the interview. We start with Dr. Flansbaum.

Dr. Whitcomb: It appears that patients are caught in the middle of the observation status challenge, at least as it relates to footing the bill. Explain the patient perspective of being unwittingly placed on observation status.

Dr. Flansbaum: Recall your last credit card statement. On it is the hotel charge from your last out-of-town CME excursion. Below the total charge, which you were expecting, is a separate line item for a $75 “recreational fee.” You call the hotel, and they inform you that, because you used the hotel gym and pool—accessed with your room key, they levied the fee. No signs, alerts, or postings denoted the policy, so you expected inclusive use of the facilities as a price of your visit. Capture the emotion of the moment, when you see that bill, feel your heart race, and think to yourself, “Get me the manager!”

WW: Why has assigning appropriate status captured the attention of hospitals?

BF: Out of vigilance for penalties and fraud from recovery audit contractor (RAC) investigations, as well attentiveness to unnecessary readmissions, hospitals increasingly are categorizing patients under observation, rather than inpatient, status to avoid conflict with regulators. Beneficiaries are in the crosshairs because of this designation change, and much in the same way of our hotel charge, our patients experience sticker shock when they receive their bill. It is leading to confusion among providers and consternation within the Medicare recipient community.

WW: Why is there so much confusion around appropriate patient status?

BF: The dilemma stems from Medicare payment, and the key distinction between inpatient coverage (Part A) and outpatient coverage, including pharmaceuticals (Parts B and D). When a patient receives their discharge notification—without an “official” inpatient designation, sometimes staying greater than 24 to 48 hours in the ED or in a specially defined observation unit, beneficiary charges are different. This could result in discrete—and sometimes jolting—enrollee copayments and deductibles for drugs and services.

WW: I’ve heard observation status is having a big, adverse impact on patients who go to skilled nursing facilities. Why?

BF: If a patient requires a skilled nursing facility stay (the “three-day stay” inpatient requirement), Medicare will not pay because the patient never registered “official” hospital time. Patients and caregivers are not prepared for the unexpected bills, and consequently, tempers are rising. The rules for Medicare Advantage enrollees (Part C—commercial payers receive a fixed sum from CMS, and oversee parts A, B, and D for an individual beneficiary), which comprise 25% of the program, differ from conventional Medicare. However, commercial plans often shadow traditional, fee-for-service in their policies and, consequently, no exemplar of success in this realm exits.

WW: Why is the number of patients on observation status growing?

BF: Hospitals have significantly increased both the number of their observation stays, as well as their hourly lengths (>48 hours). Because the definition of “observation status” is vague, and even the one- to two-day window is inflating, hospitals and hospitalists often are navigating without a compass. Again, fear of fraud and penalty places hospitals and, indirectly, hospitalists—who often make judgments on admission grade—in a precarious position.

The responsibility of hospitals to notify beneficiaries of their status hinges on this murky determination milieu, which may change in real time during the stay, and makes for an unsatisfactory standard. Understandably, CMS is attempting to rectify this quandary, taking into account a hospital’s need to clarify its billing and designation practices, as well as the beneficiaries’ desire to obtain clear guidance on their responsibilities both during and after the stay. Hospitalists, of course, want direction on coding, along with an understanding of the impact their decisions will have on patients and subspecialty colleagues.

Let’s now bring in Dr. Conway, a pediatric hospitalist. I thank Dr. Flansbaum, who formulated the following questions.

BF/WW: Is it tenable to keep the current system in place? Would it help to require payors and providers to inform beneficiaries of inpatient versus observation status at time zero in a more rigorous, yet to-be-determined manner?

Dr. Conway: Current regulations only require CMS to inform beneficiaries when they are admitted as an inpatient and not when they are an outpatient receiving observation services. There are important implications for beneficiary coverage post-hospital stay, coverage of self-administered drugs, and beneficiary coinsurance from this distinction. As a hospitalist, I think it is best to inform the patient of their status, especially if it has the potential to impact beneficiary liability, including coverage of post-acute care. CMS prepared a pamphlet in 2009, “Are You a Hospital Inpatient or Outpatient? If You Have Medicare, Ask,” to educate beneficiaries on this issue. (Download a PDF of the pamphlet at www.medicare.gov/Publications/Pubs/pdf/11435.pdf.)

BF/WW: Due to the nature of how hospital care is changing, are admission decisions potentially becoming too conflicted an endeavor for inpatient caregivers?  

PC: We want admission decisions to be based on clinical considerations. The decision to admit a patient should be based on the clinical judgment of the primary-care, emergency medicine, and/or HM clinician.

BF/WW: Before the U.S. healthcare system matures to a more full-out, integrated model with internalized risk, can you envision any near-term code changes that might simplify the difficulties all parties are facing, in a budget-neutral fashion?

PC: CMS is currently investigating options to clarify when it is appropriate to admit the patient as an inpatient versus keeping the patient as an outpatient receiving observation services. We understand that this issue is of concern to hospitals, hospitalists, and patients, and we are considering carefully how to simplify the rules in a way that best meets the needs of patients and providers without increasing costs to the system.

With growing attention to observation status coming from patients and provider groups (the AMA is requesting that CMS revise its coverage rules), we will no doubt be hearing more about this going forward.

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

EDITOR’S NOTE: An incorrect version of Win Whitcomb’s “On the Horizon” column was published in the July issue of The Hospitalist. We deeply regret the error. The correct version of Dr. Whitcomb’s column appears this month, with proper attribution given to hospitalist Brad Flansbaum, DO, SFHM, who contributed to the column.

Assigning the appropriate status to patients (“inpatient” or “observation”) has emerged as a front-and-center issue for hospitalists. Also known as “medical necessity,” many HM groups have been called upon to help solve the “status” problem for their institutions. With nearly 1 in 5 hospitalized patients on observation status in U.S. hospitals, appropriately assigning status is now a dominant, system-level challenge for hospitalists.

This month, we asked two experts to shed light on the nature of this beast, with a focus on the impact on the patient. Brad Flansbaum, DO, SFHM, hospitalist at Lenox Hill Hospital in New York City, and Patrick Conway, MD, FAAP, MSC, SFHM, chief medical officer at the Centers for Medicare & Medicaid Services (CMS), were kind enough to participate in the interview. We start with Dr. Flansbaum.

Dr. Whitcomb: It appears that patients are caught in the middle of the observation status challenge, at least as it relates to footing the bill. Explain the patient perspective of being unwittingly placed on observation status.

Dr. Flansbaum: Recall your last credit card statement. On it is the hotel charge from your last out-of-town CME excursion. Below the total charge, which you were expecting, is a separate line item for a $75 “recreational fee.” You call the hotel, and they inform you that, because you used the hotel gym and pool—accessed with your room key, they levied the fee. No signs, alerts, or postings denoted the policy, so you expected inclusive use of the facilities as a price of your visit. Capture the emotion of the moment, when you see that bill, feel your heart race, and think to yourself, “Get me the manager!”

WW: Why has assigning appropriate status captured the attention of hospitals?

BF: Out of vigilance for penalties and fraud from recovery audit contractor (RAC) investigations, as well attentiveness to unnecessary readmissions, hospitals increasingly are categorizing patients under observation, rather than inpatient, status to avoid conflict with regulators. Beneficiaries are in the crosshairs because of this designation change, and much in the same way of our hotel charge, our patients experience sticker shock when they receive their bill. It is leading to confusion among providers and consternation within the Medicare recipient community.

WW: Why is there so much confusion around appropriate patient status?

BF: The dilemma stems from Medicare payment, and the key distinction between inpatient coverage (Part A) and outpatient coverage, including pharmaceuticals (Parts B and D). When a patient receives their discharge notification—without an “official” inpatient designation, sometimes staying greater than 24 to 48 hours in the ED or in a specially defined observation unit, beneficiary charges are different. This could result in discrete—and sometimes jolting—enrollee copayments and deductibles for drugs and services.

WW: I’ve heard observation status is having a big, adverse impact on patients who go to skilled nursing facilities. Why?

BF: If a patient requires a skilled nursing facility stay (the “three-day stay” inpatient requirement), Medicare will not pay because the patient never registered “official” hospital time. Patients and caregivers are not prepared for the unexpected bills, and consequently, tempers are rising. The rules for Medicare Advantage enrollees (Part C—commercial payers receive a fixed sum from CMS, and oversee parts A, B, and D for an individual beneficiary), which comprise 25% of the program, differ from conventional Medicare. However, commercial plans often shadow traditional, fee-for-service in their policies and, consequently, no exemplar of success in this realm exits.

WW: Why is the number of patients on observation status growing?

BF: Hospitals have significantly increased both the number of their observation stays, as well as their hourly lengths (>48 hours). Because the definition of “observation status” is vague, and even the one- to two-day window is inflating, hospitals and hospitalists often are navigating without a compass. Again, fear of fraud and penalty places hospitals and, indirectly, hospitalists—who often make judgments on admission grade—in a precarious position.

The responsibility of hospitals to notify beneficiaries of their status hinges on this murky determination milieu, which may change in real time during the stay, and makes for an unsatisfactory standard. Understandably, CMS is attempting to rectify this quandary, taking into account a hospital’s need to clarify its billing and designation practices, as well as the beneficiaries’ desire to obtain clear guidance on their responsibilities both during and after the stay. Hospitalists, of course, want direction on coding, along with an understanding of the impact their decisions will have on patients and subspecialty colleagues.

Let’s now bring in Dr. Conway, a pediatric hospitalist. I thank Dr. Flansbaum, who formulated the following questions.

BF/WW: Is it tenable to keep the current system in place? Would it help to require payors and providers to inform beneficiaries of inpatient versus observation status at time zero in a more rigorous, yet to-be-determined manner?

Dr. Conway: Current regulations only require CMS to inform beneficiaries when they are admitted as an inpatient and not when they are an outpatient receiving observation services. There are important implications for beneficiary coverage post-hospital stay, coverage of self-administered drugs, and beneficiary coinsurance from this distinction. As a hospitalist, I think it is best to inform the patient of their status, especially if it has the potential to impact beneficiary liability, including coverage of post-acute care. CMS prepared a pamphlet in 2009, “Are You a Hospital Inpatient or Outpatient? If You Have Medicare, Ask,” to educate beneficiaries on this issue. (Download a PDF of the pamphlet at www.medicare.gov/Publications/Pubs/pdf/11435.pdf.)

BF/WW: Due to the nature of how hospital care is changing, are admission decisions potentially becoming too conflicted an endeavor for inpatient caregivers?  

PC: We want admission decisions to be based on clinical considerations. The decision to admit a patient should be based on the clinical judgment of the primary-care, emergency medicine, and/or HM clinician.

BF/WW: Before the U.S. healthcare system matures to a more full-out, integrated model with internalized risk, can you envision any near-term code changes that might simplify the difficulties all parties are facing, in a budget-neutral fashion?

PC: CMS is currently investigating options to clarify when it is appropriate to admit the patient as an inpatient versus keeping the patient as an outpatient receiving observation services. We understand that this issue is of concern to hospitals, hospitalists, and patients, and we are considering carefully how to simplify the rules in a way that best meets the needs of patients and providers without increasing costs to the system.

With growing attention to observation status coming from patients and provider groups (the AMA is requesting that CMS revise its coverage rules), we will no doubt be hearing more about this going forward.

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

EDITOR’S NOTE: An incorrect version of Win Whitcomb’s “On the Horizon” column was published in the July issue of The Hospitalist. We deeply regret the error. The correct version of Dr. Whitcomb’s column appears this month, with proper attribution given to hospitalist Brad Flansbaum, DO, SFHM, who contributed to the column.

Assigning the appropriate status to patients (“inpatient” or “observation”) has emerged as a front-and-center issue for hospitalists. Also known as “medical necessity,” many HM groups have been called upon to help solve the “status” problem for their institutions. With nearly 1 in 5 hospitalized patients on observation status in U.S. hospitals, appropriately assigning status is now a dominant, system-level challenge for hospitalists.

This month, we asked two experts to shed light on the nature of this beast, with a focus on the impact on the patient. Brad Flansbaum, DO, SFHM, hospitalist at Lenox Hill Hospital in New York City, and Patrick Conway, MD, FAAP, MSC, SFHM, chief medical officer at the Centers for Medicare & Medicaid Services (CMS), were kind enough to participate in the interview. We start with Dr. Flansbaum.

Dr. Whitcomb: It appears that patients are caught in the middle of the observation status challenge, at least as it relates to footing the bill. Explain the patient perspective of being unwittingly placed on observation status.

Dr. Flansbaum: Recall your last credit card statement. On it is the hotel charge from your last out-of-town CME excursion. Below the total charge, which you were expecting, is a separate line item for a $75 “recreational fee.” You call the hotel, and they inform you that, because you used the hotel gym and pool—accessed with your room key, they levied the fee. No signs, alerts, or postings denoted the policy, so you expected inclusive use of the facilities as a price of your visit. Capture the emotion of the moment, when you see that bill, feel your heart race, and think to yourself, “Get me the manager!”

WW: Why has assigning appropriate status captured the attention of hospitals?

BF: Out of vigilance for penalties and fraud from recovery audit contractor (RAC) investigations, as well attentiveness to unnecessary readmissions, hospitals increasingly are categorizing patients under observation, rather than inpatient, status to avoid conflict with regulators. Beneficiaries are in the crosshairs because of this designation change, and much in the same way of our hotel charge, our patients experience sticker shock when they receive their bill. It is leading to confusion among providers and consternation within the Medicare recipient community.

WW: Why is there so much confusion around appropriate patient status?

BF: The dilemma stems from Medicare payment, and the key distinction between inpatient coverage (Part A) and outpatient coverage, including pharmaceuticals (Parts B and D). When a patient receives their discharge notification—without an “official” inpatient designation, sometimes staying greater than 24 to 48 hours in the ED or in a specially defined observation unit, beneficiary charges are different. This could result in discrete—and sometimes jolting—enrollee copayments and deductibles for drugs and services.

WW: I’ve heard observation status is having a big, adverse impact on patients who go to skilled nursing facilities. Why?

BF: If a patient requires a skilled nursing facility stay (the “three-day stay” inpatient requirement), Medicare will not pay because the patient never registered “official” hospital time. Patients and caregivers are not prepared for the unexpected bills, and consequently, tempers are rising. The rules for Medicare Advantage enrollees (Part C—commercial payers receive a fixed sum from CMS, and oversee parts A, B, and D for an individual beneficiary), which comprise 25% of the program, differ from conventional Medicare. However, commercial plans often shadow traditional, fee-for-service in their policies and, consequently, no exemplar of success in this realm exits.

WW: Why is the number of patients on observation status growing?

BF: Hospitals have significantly increased both the number of their observation stays, as well as their hourly lengths (>48 hours). Because the definition of “observation status” is vague, and even the one- to two-day window is inflating, hospitals and hospitalists often are navigating without a compass. Again, fear of fraud and penalty places hospitals and, indirectly, hospitalists—who often make judgments on admission grade—in a precarious position.

The responsibility of hospitals to notify beneficiaries of their status hinges on this murky determination milieu, which may change in real time during the stay, and makes for an unsatisfactory standard. Understandably, CMS is attempting to rectify this quandary, taking into account a hospital’s need to clarify its billing and designation practices, as well as the beneficiaries’ desire to obtain clear guidance on their responsibilities both during and after the stay. Hospitalists, of course, want direction on coding, along with an understanding of the impact their decisions will have on patients and subspecialty colleagues.

Let’s now bring in Dr. Conway, a pediatric hospitalist. I thank Dr. Flansbaum, who formulated the following questions.

BF/WW: Is it tenable to keep the current system in place? Would it help to require payors and providers to inform beneficiaries of inpatient versus observation status at time zero in a more rigorous, yet to-be-determined manner?

Dr. Conway: Current regulations only require CMS to inform beneficiaries when they are admitted as an inpatient and not when they are an outpatient receiving observation services. There are important implications for beneficiary coverage post-hospital stay, coverage of self-administered drugs, and beneficiary coinsurance from this distinction. As a hospitalist, I think it is best to inform the patient of their status, especially if it has the potential to impact beneficiary liability, including coverage of post-acute care. CMS prepared a pamphlet in 2009, “Are You a Hospital Inpatient or Outpatient? If You Have Medicare, Ask,” to educate beneficiaries on this issue. (Download a PDF of the pamphlet at www.medicare.gov/Publications/Pubs/pdf/11435.pdf.)

BF/WW: Due to the nature of how hospital care is changing, are admission decisions potentially becoming too conflicted an endeavor for inpatient caregivers?  

PC: We want admission decisions to be based on clinical considerations. The decision to admit a patient should be based on the clinical judgment of the primary-care, emergency medicine, and/or HM clinician.

BF/WW: Before the U.S. healthcare system matures to a more full-out, integrated model with internalized risk, can you envision any near-term code changes that might simplify the difficulties all parties are facing, in a budget-neutral fashion?

PC: CMS is currently investigating options to clarify when it is appropriate to admit the patient as an inpatient versus keeping the patient as an outpatient receiving observation services. We understand that this issue is of concern to hospitals, hospitalists, and patients, and we are considering carefully how to simplify the rules in a way that best meets the needs of patients and providers without increasing costs to the system.

With growing attention to observation status coming from patients and provider groups (the AMA is requesting that CMS revise its coverage rules), we will no doubt be hearing more about this going forward.

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

When Harbor UCLA Medical Center, a teaching hospital in Torrance, Calif., and a major safety-net facility for Los Angeles County, looked at its 30-day readmissions data, it found that readmissions for heart failure patients had increased by about 25% in just one year.

“We parsed the data and said we’re going have to sort this out,” explains Charles McKay, MD, a cardiologist at the hospital. “Then the opportunity to join Project BOOST came along. It’s been helpful to have their tools, mentors, and the whole collaborative experience.”

Harbor UCLA is one of seven Southern California hospitals participating in the yearlong Readmissions Reduction Collaborative, co-sponsored by SHM and the Hospital Association of Southern California (HASC). The hospitals convened in early June in Montebello, Calif., to report results from their quality initiatives. Four of the hospitals reported reductions in readmissions ranging from 24% to 55%. The other three were slower in implementing their quality processes and are just now starting to see results, executives said.

Project BOOST is a national quality initiative created by SHM to improve hospital discharges and care transitions while reducing readmissions—a growing focus for hospitals and health policy makers. About 100 participating sites across the country have benefited from BOOST’s expert mentoring and collaboration, as well as access to such tools as the “teachback” communication techniques and the “8Ps” comprehensive patient risk assessment.

Harbor UCLA’s multidisciplinary readmissions team, with Dr. McKay as its physician champion, zeroed in on heart failure and developed a Cardiovascular Open Access Rapid Evaluation (CORE) service, which he describes as a sort of observation or clinical decisions unit aimed at relieving pressure on the ED. Open 7 a.m. to 7 p.m., the CORE service coordinates medical interventions—stress tests and trips to the cardiac catheter lab, for example—for patients who have not been admitted to the hospital.

The team also focuses on discharged patients who return to the hospital within 72 hours, before the hospital could place post-discharge follow-up phone calls. Many of these patients could not be reached after they left the hospital.

“These are the patients where the system has failed,” Dr. McKay says. “But you could flip it over and say they are our biggest opportunity. That’s where BOOST comes in, to talk about interventions during hospitalization, implementing teachback, streamlining the coordination of care.”

BOOST aims to accelerate the quality-improvement (QI) process, identifying readmission risks and making them a higher priority for nurses and doctors to mobilize resources in the discharge process. “That’s where BOOST shone at our institution,” Dr. McKay says, “and where we still have a lot to learn.”

Harbor UCLA also brought a home healthcare representative onto the team, engaged a discharge advocate, and referred appropriate patients to a heart failure disease management registry. Over the year of the collaborative, it posted a 5.5% decrease in readmissions of heart failure patients.

Hospitalists do not have prominent roles at most HASC readmissions sites; traditional hospitalist services are less common in Southern California hospitals, in part due to the prevalence of independent practice associations (IPAs), which act as intermediaries between physicians and health plans in the region, explains Z. Joseph Wanski, MD, FACE, medical director of the public L.A. Care Health Plan, which co-sponsored the readmissions collaborative. “The IPA is in charge of its members’ hospital and post-hospital care,” he says.

Dr. Wanski, a practicing endocrinologist and a hospitalist at California Hospital Medical Center in Los Angeles, says L.A. Care is now testing the use of hospitalists at some of its contracted acute-care facilities.

In many cases, readmissions involve avoidable costs, as well as reduce patient satisfaction. “If they do not get rehospitalized, patients are happier, their caretakers are happier, and I feel the quality of their care is better,” Dr. Wanski says. “If you can keep the person well at home, make sure they take their medications, hopefully not go back to the ER, and get on with their lives—all those things together are why we’re supporting this collaborative.”

But hospitalists, especially in larger groups, potentially have the leverage to negotiate access to services and the care coordination needed to reduce hospital costs and preventable readmissions, Dr. McKay notes. “In 2012, hospitalists are key, and we need to find a way to make readmission reduction part of their job description, so that they can direct that,” he says.

At Valley Presbyterian Hospital in Van Nuys, which employs three part-time hospitalists who also maintain busy office practices, “the hospitalists have been very cooperative with our project,” reports Adriana Quintero, MSW, the hospital’s full-time Project BOOST facilitator. “They see a lot of our patients in their offices.” The physicians have agreed to carve out time to see, within seven days, discharge patients going home without scheduled appointments with their primary-care physicians (PCPs).

“We find that many of our discharged patients do not call their primary-care physicians for post-discharge appointments” and decline the hospital team’s offers for help—which makes it important for the discharge coordinator to follow up as soon as possible after the patient goes home, Quintero says.

At the collaborative congress in early June, team member Alice Gunderson reported results for Saint Francis Hospital in Lynwood. Gunderson, who sits on the hospital’s quality and safety board, has been a volunteer patient family advocate (PFA) for the past year and a half; she was inspired by her own experience as a family caregiver for her husband and mother, both of whom were Saint Francis patients. Gunderson challenged those in the audience to bring a PFA from their own hospital to the next BOOST meeting.

“From my point of view, wherever healthcare goes, the patient is becoming more educated, with all of the communication technology that is out there, and claiming that empowerment,” Gunderson says. “We must all work together, not in separate silos, for the best outcomes, and we can all learn from one another.”

Larry Beresford is a freelance writer in Oakland, Calif.

When Harbor UCLA Medical Center, a teaching hospital in Torrance, Calif., and a major safety-net facility for Los Angeles County, looked at its 30-day readmissions data, it found that readmissions for heart failure patients had increased by about 25% in just one year.

“We parsed the data and said we’re going have to sort this out,” explains Charles McKay, MD, a cardiologist at the hospital. “Then the opportunity to join Project BOOST came along. It’s been helpful to have their tools, mentors, and the whole collaborative experience.”

Harbor UCLA is one of seven Southern California hospitals participating in the yearlong Readmissions Reduction Collaborative, co-sponsored by SHM and the Hospital Association of Southern California (HASC). The hospitals convened in early June in Montebello, Calif., to report results from their quality initiatives. Four of the hospitals reported reductions in readmissions ranging from 24% to 55%. The other three were slower in implementing their quality processes and are just now starting to see results, executives said.

Project BOOST is a national quality initiative created by SHM to improve hospital discharges and care transitions while reducing readmissions—a growing focus for hospitals and health policy makers. About 100 participating sites across the country have benefited from BOOST’s expert mentoring and collaboration, as well as access to such tools as the “teachback” communication techniques and the “8Ps” comprehensive patient risk assessment.

Harbor UCLA’s multidisciplinary readmissions team, with Dr. McKay as its physician champion, zeroed in on heart failure and developed a Cardiovascular Open Access Rapid Evaluation (CORE) service, which he describes as a sort of observation or clinical decisions unit aimed at relieving pressure on the ED. Open 7 a.m. to 7 p.m., the CORE service coordinates medical interventions—stress tests and trips to the cardiac catheter lab, for example—for patients who have not been admitted to the hospital.

The team also focuses on discharged patients who return to the hospital within 72 hours, before the hospital could place post-discharge follow-up phone calls. Many of these patients could not be reached after they left the hospital.

“These are the patients where the system has failed,” Dr. McKay says. “But you could flip it over and say they are our biggest opportunity. That’s where BOOST comes in, to talk about interventions during hospitalization, implementing teachback, streamlining the coordination of care.”

BOOST aims to accelerate the quality-improvement (QI) process, identifying readmission risks and making them a higher priority for nurses and doctors to mobilize resources in the discharge process. “That’s where BOOST shone at our institution,” Dr. McKay says, “and where we still have a lot to learn.”

Harbor UCLA also brought a home healthcare representative onto the team, engaged a discharge advocate, and referred appropriate patients to a heart failure disease management registry. Over the year of the collaborative, it posted a 5.5% decrease in readmissions of heart failure patients.

Hospitalists do not have prominent roles at most HASC readmissions sites; traditional hospitalist services are less common in Southern California hospitals, in part due to the prevalence of independent practice associations (IPAs), which act as intermediaries between physicians and health plans in the region, explains Z. Joseph Wanski, MD, FACE, medical director of the public L.A. Care Health Plan, which co-sponsored the readmissions collaborative. “The IPA is in charge of its members’ hospital and post-hospital care,” he says.

Dr. Wanski, a practicing endocrinologist and a hospitalist at California Hospital Medical Center in Los Angeles, says L.A. Care is now testing the use of hospitalists at some of its contracted acute-care facilities.

In many cases, readmissions involve avoidable costs, as well as reduce patient satisfaction. “If they do not get rehospitalized, patients are happier, their caretakers are happier, and I feel the quality of their care is better,” Dr. Wanski says. “If you can keep the person well at home, make sure they take their medications, hopefully not go back to the ER, and get on with their lives—all those things together are why we’re supporting this collaborative.”

But hospitalists, especially in larger groups, potentially have the leverage to negotiate access to services and the care coordination needed to reduce hospital costs and preventable readmissions, Dr. McKay notes. “In 2012, hospitalists are key, and we need to find a way to make readmission reduction part of their job description, so that they can direct that,” he says.

At Valley Presbyterian Hospital in Van Nuys, which employs three part-time hospitalists who also maintain busy office practices, “the hospitalists have been very cooperative with our project,” reports Adriana Quintero, MSW, the hospital’s full-time Project BOOST facilitator. “They see a lot of our patients in their offices.” The physicians have agreed to carve out time to see, within seven days, discharge patients going home without scheduled appointments with their primary-care physicians (PCPs).

“We find that many of our discharged patients do not call their primary-care physicians for post-discharge appointments” and decline the hospital team’s offers for help—which makes it important for the discharge coordinator to follow up as soon as possible after the patient goes home, Quintero says.

At the collaborative congress in early June, team member Alice Gunderson reported results for Saint Francis Hospital in Lynwood. Gunderson, who sits on the hospital’s quality and safety board, has been a volunteer patient family advocate (PFA) for the past year and a half; she was inspired by her own experience as a family caregiver for her husband and mother, both of whom were Saint Francis patients. Gunderson challenged those in the audience to bring a PFA from their own hospital to the next BOOST meeting.

“From my point of view, wherever healthcare goes, the patient is becoming more educated, with all of the communication technology that is out there, and claiming that empowerment,” Gunderson says. “We must all work together, not in separate silos, for the best outcomes, and we can all learn from one another.”

Larry Beresford is a freelance writer in Oakland, Calif.

When Harbor UCLA Medical Center, a teaching hospital in Torrance, Calif., and a major safety-net facility for Los Angeles County, looked at its 30-day readmissions data, it found that readmissions for heart failure patients had increased by about 25% in just one year.

“We parsed the data and said we’re going have to sort this out,” explains Charles McKay, MD, a cardiologist at the hospital. “Then the opportunity to join Project BOOST came along. It’s been helpful to have their tools, mentors, and the whole collaborative experience.”

Harbor UCLA is one of seven Southern California hospitals participating in the yearlong Readmissions Reduction Collaborative, co-sponsored by SHM and the Hospital Association of Southern California (HASC). The hospitals convened in early June in Montebello, Calif., to report results from their quality initiatives. Four of the hospitals reported reductions in readmissions ranging from 24% to 55%. The other three were slower in implementing their quality processes and are just now starting to see results, executives said.

Project BOOST is a national quality initiative created by SHM to improve hospital discharges and care transitions while reducing readmissions—a growing focus for hospitals and health policy makers. About 100 participating sites across the country have benefited from BOOST’s expert mentoring and collaboration, as well as access to such tools as the “teachback” communication techniques and the “8Ps” comprehensive patient risk assessment.

Harbor UCLA’s multidisciplinary readmissions team, with Dr. McKay as its physician champion, zeroed in on heart failure and developed a Cardiovascular Open Access Rapid Evaluation (CORE) service, which he describes as a sort of observation or clinical decisions unit aimed at relieving pressure on the ED. Open 7 a.m. to 7 p.m., the CORE service coordinates medical interventions—stress tests and trips to the cardiac catheter lab, for example—for patients who have not been admitted to the hospital.

The team also focuses on discharged patients who return to the hospital within 72 hours, before the hospital could place post-discharge follow-up phone calls. Many of these patients could not be reached after they left the hospital.

“These are the patients where the system has failed,” Dr. McKay says. “But you could flip it over and say they are our biggest opportunity. That’s where BOOST comes in, to talk about interventions during hospitalization, implementing teachback, streamlining the coordination of care.”

BOOST aims to accelerate the quality-improvement (QI) process, identifying readmission risks and making them a higher priority for nurses and doctors to mobilize resources in the discharge process. “That’s where BOOST shone at our institution,” Dr. McKay says, “and where we still have a lot to learn.”

Harbor UCLA also brought a home healthcare representative onto the team, engaged a discharge advocate, and referred appropriate patients to a heart failure disease management registry. Over the year of the collaborative, it posted a 5.5% decrease in readmissions of heart failure patients.

Hospitalists do not have prominent roles at most HASC readmissions sites; traditional hospitalist services are less common in Southern California hospitals, in part due to the prevalence of independent practice associations (IPAs), which act as intermediaries between physicians and health plans in the region, explains Z. Joseph Wanski, MD, FACE, medical director of the public L.A. Care Health Plan, which co-sponsored the readmissions collaborative. “The IPA is in charge of its members’ hospital and post-hospital care,” he says.

Dr. Wanski, a practicing endocrinologist and a hospitalist at California Hospital Medical Center in Los Angeles, says L.A. Care is now testing the use of hospitalists at some of its contracted acute-care facilities.

In many cases, readmissions involve avoidable costs, as well as reduce patient satisfaction. “If they do not get rehospitalized, patients are happier, their caretakers are happier, and I feel the quality of their care is better,” Dr. Wanski says. “If you can keep the person well at home, make sure they take their medications, hopefully not go back to the ER, and get on with their lives—all those things together are why we’re supporting this collaborative.”

But hospitalists, especially in larger groups, potentially have the leverage to negotiate access to services and the care coordination needed to reduce hospital costs and preventable readmissions, Dr. McKay notes. “In 2012, hospitalists are key, and we need to find a way to make readmission reduction part of their job description, so that they can direct that,” he says.

At Valley Presbyterian Hospital in Van Nuys, which employs three part-time hospitalists who also maintain busy office practices, “the hospitalists have been very cooperative with our project,” reports Adriana Quintero, MSW, the hospital’s full-time Project BOOST facilitator. “They see a lot of our patients in their offices.” The physicians have agreed to carve out time to see, within seven days, discharge patients going home without scheduled appointments with their primary-care physicians (PCPs).

“We find that many of our discharged patients do not call their primary-care physicians for post-discharge appointments” and decline the hospital team’s offers for help—which makes it important for the discharge coordinator to follow up as soon as possible after the patient goes home, Quintero says.

At the collaborative congress in early June, team member Alice Gunderson reported results for Saint Francis Hospital in Lynwood. Gunderson, who sits on the hospital’s quality and safety board, has been a volunteer patient family advocate (PFA) for the past year and a half; she was inspired by her own experience as a family caregiver for her husband and mother, both of whom were Saint Francis patients. Gunderson challenged those in the audience to bring a PFA from their own hospital to the next BOOST meeting.

“From my point of view, wherever healthcare goes, the patient is becoming more educated, with all of the communication technology that is out there, and claiming that empowerment,” Gunderson says. “We must all work together, not in separate silos, for the best outcomes, and we can all learn from one another.”

Larry Beresford is a freelance writer in Oakland, Calif.

Quotes from the Field

We cannot rely solely on a tool to make decisions. The tool is a decision aid.

Alvin H. Moss, MD, FAAHPM

Professor of medicine in the nephrology section and director of the Center for Health Ethics and Law at West Virginia University School of Medicine in Morgantown

 

Predictions really apply to groups of people, not individuals.

J. Randall Curtis, MD, MPH

Professor and section head in the division of pulmonary and critical care medicine at the University of Washington’s Harborview Medical Center in Seattle

 

if you ask a physician to provide you with his or her impression of a patient progression, we generally tend to overestimate how well they’re doing.

JoAnn Wood, MD, MSEd, MHA

Hospitalist and division director of general internal medicine at the University of Arkansas for Medical Sciences in Little Rock

 

Patients feel that you’re almost abandoning them, that there’s something you’re withholding.

Ann Sheehy

Director of the hospitalist service at University of Wisconsin Medical Center in Madison

 

Telling patients there is a 20% chance that they might die in the next year isn’t usually enough to change their thinking.

David Casarett, MD, MA

Associate professor of medicine at the University of Pennsylvania and chief medical officer of Penn-Wissahickon Hospice in Philadelphia

End-of-life conversations are common in hospital medicine, and Caitlin Foxley, MD, FHM, is no stranger to their nuance. She offers patients and loved ones as much factual information as she can. And regardless of their preference—aggressive treatment, comfort care, something in between—it’s ultimately their choice, not hers. But no matter what, she will ensure the patient’s pain remains under control.

“The way I practice is to allow my patients to make the end-of-life decision that is in accordance with their wishes, and not simply push the least expensive one on them,” says Dr. Foxley, medical director of IMI Hospitalists and hospital service chief of internal medicine at Nebraska Medical Center in Omaha. However, she adds, “most people, given accurate information in a compassionate manner, would choose to die at home, and not in an ICU on a ventilator, with chemo and pressers going through a central line.”

Although hospitalists differ in their approaches to end-of-life discussions, most agree that the majority of critically ill patients want to know their prognosis. Tested end-of-life prediction tools can help physicians provide realistic ranges for patients and families (see “Helpful End-of-Life Prediction Tools,” p. 39). Armed with this insight, they can hope to deliver better and more cost-effective end-of-life care.

Nonetheless, “we cannot rely solely on a tool to make decisions,” says Alvin H. Moss, MD, FAAHPM, professor of medicine in the nephrology section and director of the Center for Health Ethics and Law at West Virginia University School of Medicine in Morgantown. “The tool is a decision aid.”

Clinicians still need to help patients and families identify their treatment goals while determining which life-sustaining options they would or wouldn’t want to pursue, Dr. Moss says. That conversation would include an estimated prognosis of survival.

“If you try to prognosticate a specific length of time, you will be wrong,” says Steven Z. Pantilat, MD, FACP, SFHM, professor of clinical medicine and director of the palliative care program at the University of California San Francisco Medical Center. “You can give patients a lot of useful information by speaking in ranges.”

But it’s important to also convey the inherent uncertainty of any prognosis, considering that a very sick patient might suffer a sudden decline. For this reason, even the best prognostic indicators aren’t exact, Dr. Pantilat cautions. A prediction tool could forecast a 20% chance of six-month survival on the day before a patient’s death in the ICU.

“Predictions really apply to groups of people, not individuals,” says J. Randall Curtis, MD, MPH, professor and section head in the division of pulmonary and critical care medicine at the University of Washington’s Harborview Medical Center in Seattle. Physicians can’t possibly know whether someone will fall into the 95% of patients who die or the 5% of patients who beat the odds.

“It’s never certain that a patient is not going to survive,” says Dr. Curtis, who is director of the Harborview/University of Washington End-of-Life Care Research Program. While patients are less likely to request aggressive care in light of a poor prognosis, some will elect intensive treatment in hopes of defying even the grimmest statistics.

More Medical Tests and Procedures

In the U.S., it’s much more common for patients to receive life-saving treatments than in other countries. The expectation is that expensive medical technology can always prolong life.¹

“A lot of patients have that mentality,” says Ann Sheehy, MD, MS, director of the hospitalist service at University of Wisconsin Medical Center in Madison. “That makes it harder to have the discussion with patients that there isn’t something else we can do.” Patients feel “that you’re almost abandoning them, that there’s something you’re withholding.”

The widespread assumption that more medical tests and procedures lead to better outcomes goes hand in hand with the misperception that sufficiently controlling pain and other symptoms draws death closer. As a result, many patients end up dying with distressing symptoms in the hospital instead of peacefully at home.¹

As physicians, Dr. Sheehy points out, “We don’t do a good job of saying, ‘This care probably is not going to help you or that it will leave you with a very bad quality of life in the end.’” But projections are far from perfect.

“Telling patients there is a 20% chance that they might die in the next year isn’t usually enough to change their thinking. Nor is it enough to justify withholding treatment,” says David Casarett, MD, MA, associate professor of medicine at the University of Pennsylvania and chief medical officer of Penn-Wissahickon Hospice in Philadelphia.

What prognostic information can do is play an important part in guiding appropriate screening and preventive health measures. For example, if a male patient has a 50% chance of dying within four years, it doesn’t make sense to screen for prostate cancer, a slow-growing malignancy that often takes years to develop. This protocol may also apply to cancer screenings, as well as treatments for diabetes, high blood pressure, or high cholesterol, Dr. Casarett says. 

End-of-Life Conversations

By not taking a patient’s prognosis into account, many clinical decisions are not fully informed. In physicians’ clinical practice and training, there tends to be less emphasis on estimating prognosis than on diagnosing and treating illness. This is particularly significant in older adults with competing chronic conditions and diminished life expectancy.²

“Many physicians have not been trained in how to have these conversations, which is something we’re trying to change,” says Dr. Curtis, the pulmonary and critical care specialist at the University of Washington. “This is very emotionally difficult for patients and families, and therefore, it can also be emotionally difficult for physicians.”

Starting this summer, medical residents at Cooper University Hospital in Camden, N.J., will have mandated exposure to palliative care. The rotation, lasting from two to four weeks, will occur in their second year of training, says Mark Angelo, MD, FACP, director of palliative medicine.

Residents will accompany the palliative-care team for an intensive period of time to learn about different techniques for symptom control and to observe end-of-life conversations, which often elicit patients’ angst, depression, and physiologic and spiritual unrest.

“We already have residents rotating with us now in the palliative-care program, and everybody is very struck by how honest patients want you to be,” Dr. Angelo says. “It certainly is devastating, and we understand that. But it does give patients the opportunity to reorganize their lives and to prioritize a number of issues, including medical treatment.”

Some patients opt to spend more time with their grandchildren rather than stay in the hospital. Others prefer to eat and drink whatever they want. Many terminally ill Hispanic patients in the Camden area travel to Latin America, where they were born, or they invite relatives to visit them here, Dr. Angelo says.

While it’s difficult to accept finality, “there’s a certain amount of freedom that comes with that,” he says. “If someone has a prognosis of two months, they may make very different decisions than someone who has a prognosis of two years.”

Physicians tend to be overly optimistic, notes JoAnn Wood, MD, MSEd, MHA, a hospitalist and division director of general internal medicine at the University of Arkansas for Medical Sciences in Little Rock. “The data suggest that, if you ask a physician to provide you with his or her impression of a patient progression, we generally tend to overestimate how well they’re doing,” particularly with cancer patients, Dr. Wood says. “Physicians don’t choose this line of work to facilitate people’s dying.”

When Doing Less Is More

End-of-life prediction tools enable clinicians to keep their expectations of a patient’s survival grounded in reality. And in many hospitals, palliative-care providers are available to lend their expertise. “The field of palliative medicine has taken a lot of strides,” Dr. Wood says, “in helping us to seeing that dying is something that can be done well, just like living can be done well.”

In fact, growing evidence indicates that treating a patient’s discomfort is linked to improvement in physical status and might even increase survival.³ What this means is that, at the end of life, sometimes doing less is actually more. And if patients request less medical care, physicians should honor those desires.^4,5

Dr. Pantilat, the UCSF palliative-care expert, suggests asking open-ended questions to get at the heart of a patient’s wishes. For instance: “‘When you look to the future, what do you hope will happen?’ Or ‘When you think of life ahead, what worries you the most?’” The responses guide physicians in devising a plan of care that is consistent with a patient’s values. Having these discussions sooner rather than later is best for everyone involved, Dr. Pantilat says. Unfortunately, that’s not what usually happens.

About half of the more than 40% of Americans who die annually under hospice care do so within two weeks after being admitted. In such a short timeframe, even the most skilled experts are limited in what they can do, according to the National Hospice and Palliative Care Organization. To reverse this trend, Dr. Pantilat recommends that physicians consider making referrals to palliative care much earlier, whenever they sense that a patient may have a year or less to live.

Providing palliative care can be done in conjunction with life-prolonging therapies or as the central focus. The goal is to prevent and relieve suffering and to ensure the best possible quality of life for patients and their families, regardless of disease stage or the need for other treatments. Such care is suitable for patients with cancer, heart conditions, liver or renal failure, Alzheimer’s disease, spinal cord injuries, and a number of other illnesses, according to the National Consensus Project for Quality Palliative Care.

We have a lot of work to do to educate the public about the dying process. We are all going to die someday, and we all need to think about how and where we want to be when it happens, if we have any choice in it.

—Caitlin Foxley, MD, FHM, medical director, IMI Hospitalists, hospital service chief of internal medicine, Nebraska Medical Center, Omaha

Planning Ahead

In Arkansas, Dr. Wood typically turns to the hospital’s palliative-care team in end-of-life situations, asking its members to join in a conference with the patient and family. The team typically consists of a nurse, social worker and chaplain who can address various concerns. An employee from the medical billing department participates if necessary.

“Physicians should never assume that they understand the healthcare system, because it’s incredibly complicated,” Dr. Wood says, adding that she doesn’t pretend to be an expert in Medicare, Medicaid, or private insurance reimbursement issues.

Helping patients with advanced care planning can minimize difficulties later. Most patients who die in hospitals are admitted with end-stage disease, and most spend time in the ICU with mechanical ventilation. Physicians often are unaware of patients’ preferences, and this could lead to misunderstandings, especially in the ICU setting, where prognoses can shift quickly. One study showed that, in order for some of these patients to die, clinicians and families generally had to decide explicitly to strive toward less-than-completely-aggressive care.¹

“We’re trying to make sure that patients and families have an opportunity to do advanced-care planning,” Dr. Curtis says. Talking with them about their values and goals is essential for clinicians to understand their preferences.

Part of this involves crafting advanced-care directives. One such directive would be a power of attorney for healthcare, in which a patient states who is authorized to make decisions if he or she becomes unable to do so. This is particularly important for patients who select someone other than whom their state’s law would normally designate.

Another document—the living will—allows patients to specify their own preferences for end-of-life care. Yet “it’s often very difficult to know exactly what decisions will need to be made,” Dr. Curtis says. “Those documents are rarely determinative.” Even when a patient stipulates his or her wishes against “extraordinary life-sustaining measures, it still leaves a lot for interpretation.”

Some patients may spell out more clearly whether they wouldn’t want tube-feeding, CPR, or ventilation. This can be prescribed in written and signed Physician Orders for Life-Sustaining Treatment (POLST).

If you try to prognosticate a specific length of time, you will be wrong. You can give patients a lot of useful information by speaking in ranges.

—Steven Z. Pantilat, MD, FACP, professor of clinical medicine, director of the palliative-care program, University of California San Francisco Medical Center

Educating the Public

End-of-life discussions also pose a threat of litigation. “It takes a significant amount of time, often during a very busy day, to sit down with a patient and family members to bring up an issue that will undoubtedly raise many questions, some of which are impossible to answer,” says Dr. Foxley, the hospitalist service chief in Omaha. “I’m sure many physicians are uncomfortable with the tears that are shed.”

When Dr. Foxley recently advised a patient’s family that aggressive care would be futile, they directed their anger toward her. Their loved one died, despite the intensive treatment. It’s just one example of many in which Dr. Foxley has witnessed how high-tech medical treatments can incur astronomical hospital bills after just a few days while doing little—if anything—helpful for the patient.

“We have a lot of work to do to educate the public about the dying process,” she says, adding that the entire burden shouldn’t fall on physicians, and that patients should inform family members of their end-of-life wishes. “We are all going to die someday, and we all need to think about how and where we want to be when it happens, if we have any choice in it.”

Susan Kreimer is a freelance medical writer based in New York.

Helpful End-of-Life Prediction Tools

APACHE II (Acute Physiology and Chronic Health Evaluation II)

A severity-of-disease classification system and one of several ICU scoring systems, it is applied within 24 hours of patient admission. An integer score from 0 to 71 is computed based on several measurements; higher scores correspond to more severe disease and a higher risk of death. http://clincalc.com/IcuMortality/APACHEII.aspx

SOFA (Sequential Organ Failure Assessment)

SOFA tracks a patient’s status during an ICU stay. This scoring system determines the extent of a person’s organ function or rate of failure. The overall score is based on scores of the respiratory, cardiovascular, hepatic, coagulation, renal, and neurological systems. http://www.sfar.org/scores2/sofa2.html

The Karnofsky Performance Scale Index

This tool allows patients to be classified by functional impairment. It compares effectiveness of different therapies and assesses the prognosis in individual patients. The lower the Karnofsky score, the worse the survival outlook for most serious illnesses. http://www.hospicepatients.org/karnofsky.html

PPS (Palliative Performance Scale) 

First introduced in 1996 as a tool for performance status in palliative care, the PPS uses five observer-rated domains correlated to the Karnofsky index (100-0). PPS is used in many countries and is translated into many languages. http://supportforhome.wordpress.com/2011/06/15/palliative-performance-scale/

The BODE Index

BODE helps predict mortality from chronic obstructive pulmonary disease (COPD) after diagnosis. Presumably, a higher BODE score correlates with an increased risk of death. http://copd.about.com/od/copdbasics/a/BODEIndex.htm

The Charlson Comorbidity Index

This index predicts the 10-year mortality for a patient who might have a range of comorbid conditions, such as heart disease, AIDS, or cancer (a total of 22 conditions). Each condition is assigned a score, depending on the risk of dying associated with the condition. http://www.medal.org/OnlineCalculators/ch1/ch1.13/ch1.13.01.php

Hemodialysis Mortality Predictor

This online calculator estimates prognosis in end-stage renal disease patients using an integrated model that incorporates the patient age, serum albumin, comorbidities, and clinician assessment of the patient’s likelihood of being dead within a year. http://touchcalc.com/calculators/sq

—Susan Kreimer

References

1. Walling AM, Asch SM, Lorenz KA, et al. The quality of care provided to hospitalized patients at the end of life. Arch Intern Med. 2010;170(12):1057-1063.
2. Yourman LC, Lee SJ, Schonberg MA, Widera EW, Smith AK. Prognostic indices for older adults: a systematic review. JAMA. 2012;307(2):182-192.
3. Grudzen C, Grady D. Improving care at the end of life. Arch Intern Med. 2011;171(13):1202.
4. Grudzen C. At the end of life, sometimes less is more. Arch Intern Med. 2011;171(13):1201.
5. Bale PW. Honoring patients’ wishes for less health care. Arch Intern Med. 2011;171(13):1200.

Quotes from the Field

We cannot rely solely on a tool to make decisions. The tool is a decision aid.

Alvin H. Moss, MD, FAAHPM

Professor of medicine in the nephrology section and director of the Center for Health Ethics and Law at West Virginia University School of Medicine in Morgantown

 

Predictions really apply to groups of people, not individuals.

J. Randall Curtis, MD, MPH

Professor and section head in the division of pulmonary and critical care medicine at the University of Washington’s Harborview Medical Center in Seattle

 

if you ask a physician to provide you with his or her impression of a patient progression, we generally tend to overestimate how well they’re doing.

JoAnn Wood, MD, MSEd, MHA

Hospitalist and division director of general internal medicine at the University of Arkansas for Medical Sciences in Little Rock

 

Patients feel that you’re almost abandoning them, that there’s something you’re withholding.

Ann Sheehy

Director of the hospitalist service at University of Wisconsin Medical Center in Madison

 

Telling patients there is a 20% chance that they might die in the next year isn’t usually enough to change their thinking.

David Casarett, MD, MA

Associate professor of medicine at the University of Pennsylvania and chief medical officer of Penn-Wissahickon Hospice in Philadelphia

End-of-life conversations are common in hospital medicine, and Caitlin Foxley, MD, FHM, is no stranger to their nuance. She offers patients and loved ones as much factual information as she can. And regardless of their preference—aggressive treatment, comfort care, something in between—it’s ultimately their choice, not hers. But no matter what, she will ensure the patient’s pain remains under control.

“The way I practice is to allow my patients to make the end-of-life decision that is in accordance with their wishes, and not simply push the least expensive one on them,” says Dr. Foxley, medical director of IMI Hospitalists and hospital service chief of internal medicine at Nebraska Medical Center in Omaha. However, she adds, “most people, given accurate information in a compassionate manner, would choose to die at home, and not in an ICU on a ventilator, with chemo and pressers going through a central line.”

Although hospitalists differ in their approaches to end-of-life discussions, most agree that the majority of critically ill patients want to know their prognosis. Tested end-of-life prediction tools can help physicians provide realistic ranges for patients and families (see “Helpful End-of-Life Prediction Tools,” p. 39). Armed with this insight, they can hope to deliver better and more cost-effective end-of-life care.

Nonetheless, “we cannot rely solely on a tool to make decisions,” says Alvin H. Moss, MD, FAAHPM, professor of medicine in the nephrology section and director of the Center for Health Ethics and Law at West Virginia University School of Medicine in Morgantown. “The tool is a decision aid.”

Clinicians still need to help patients and families identify their treatment goals while determining which life-sustaining options they would or wouldn’t want to pursue, Dr. Moss says. That conversation would include an estimated prognosis of survival.

“If you try to prognosticate a specific length of time, you will be wrong,” says Steven Z. Pantilat, MD, FACP, SFHM, professor of clinical medicine and director of the palliative care program at the University of California San Francisco Medical Center. “You can give patients a lot of useful information by speaking in ranges.”

But it’s important to also convey the inherent uncertainty of any prognosis, considering that a very sick patient might suffer a sudden decline. For this reason, even the best prognostic indicators aren’t exact, Dr. Pantilat cautions. A prediction tool could forecast a 20% chance of six-month survival on the day before a patient’s death in the ICU.

“Predictions really apply to groups of people, not individuals,” says J. Randall Curtis, MD, MPH, professor and section head in the division of pulmonary and critical care medicine at the University of Washington’s Harborview Medical Center in Seattle. Physicians can’t possibly know whether someone will fall into the 95% of patients who die or the 5% of patients who beat the odds.

“It’s never certain that a patient is not going to survive,” says Dr. Curtis, who is director of the Harborview/University of Washington End-of-Life Care Research Program. While patients are less likely to request aggressive care in light of a poor prognosis, some will elect intensive treatment in hopes of defying even the grimmest statistics.

More Medical Tests and Procedures

In the U.S., it’s much more common for patients to receive life-saving treatments than in other countries. The expectation is that expensive medical technology can always prolong life.¹

“A lot of patients have that mentality,” says Ann Sheehy, MD, MS, director of the hospitalist service at University of Wisconsin Medical Center in Madison. “That makes it harder to have the discussion with patients that there isn’t something else we can do.” Patients feel “that you’re almost abandoning them, that there’s something you’re withholding.”

The widespread assumption that more medical tests and procedures lead to better outcomes goes hand in hand with the misperception that sufficiently controlling pain and other symptoms draws death closer. As a result, many patients end up dying with distressing symptoms in the hospital instead of peacefully at home.¹

As physicians, Dr. Sheehy points out, “We don’t do a good job of saying, ‘This care probably is not going to help you or that it will leave you with a very bad quality of life in the end.’” But projections are far from perfect.

“Telling patients there is a 20% chance that they might die in the next year isn’t usually enough to change their thinking. Nor is it enough to justify withholding treatment,” says David Casarett, MD, MA, associate professor of medicine at the University of Pennsylvania and chief medical officer of Penn-Wissahickon Hospice in Philadelphia.

What prognostic information can do is play an important part in guiding appropriate screening and preventive health measures. For example, if a male patient has a 50% chance of dying within four years, it doesn’t make sense to screen for prostate cancer, a slow-growing malignancy that often takes years to develop. This protocol may also apply to cancer screenings, as well as treatments for diabetes, high blood pressure, or high cholesterol, Dr. Casarett says. 

End-of-Life Conversations

By not taking a patient’s prognosis into account, many clinical decisions are not fully informed. In physicians’ clinical practice and training, there tends to be less emphasis on estimating prognosis than on diagnosing and treating illness. This is particularly significant in older adults with competing chronic conditions and diminished life expectancy.²

“Many physicians have not been trained in how to have these conversations, which is something we’re trying to change,” says Dr. Curtis, the pulmonary and critical care specialist at the University of Washington. “This is very emotionally difficult for patients and families, and therefore, it can also be emotionally difficult for physicians.”

Starting this summer, medical residents at Cooper University Hospital in Camden, N.J., will have mandated exposure to palliative care. The rotation, lasting from two to four weeks, will occur in their second year of training, says Mark Angelo, MD, FACP, director of palliative medicine.

Residents will accompany the palliative-care team for an intensive period of time to learn about different techniques for symptom control and to observe end-of-life conversations, which often elicit patients’ angst, depression, and physiologic and spiritual unrest.

“We already have residents rotating with us now in the palliative-care program, and everybody is very struck by how honest patients want you to be,” Dr. Angelo says. “It certainly is devastating, and we understand that. But it does give patients the opportunity to reorganize their lives and to prioritize a number of issues, including medical treatment.”

Some patients opt to spend more time with their grandchildren rather than stay in the hospital. Others prefer to eat and drink whatever they want. Many terminally ill Hispanic patients in the Camden area travel to Latin America, where they were born, or they invite relatives to visit them here, Dr. Angelo says.

While it’s difficult to accept finality, “there’s a certain amount of freedom that comes with that,” he says. “If someone has a prognosis of two months, they may make very different decisions than someone who has a prognosis of two years.”

Physicians tend to be overly optimistic, notes JoAnn Wood, MD, MSEd, MHA, a hospitalist and division director of general internal medicine at the University of Arkansas for Medical Sciences in Little Rock. “The data suggest that, if you ask a physician to provide you with his or her impression of a patient progression, we generally tend to overestimate how well they’re doing,” particularly with cancer patients, Dr. Wood says. “Physicians don’t choose this line of work to facilitate people’s dying.”

When Doing Less Is More

End-of-life prediction tools enable clinicians to keep their expectations of a patient’s survival grounded in reality. And in many hospitals, palliative-care providers are available to lend their expertise. “The field of palliative medicine has taken a lot of strides,” Dr. Wood says, “in helping us to seeing that dying is something that can be done well, just like living can be done well.”

In fact, growing evidence indicates that treating a patient’s discomfort is linked to improvement in physical status and might even increase survival.³ What this means is that, at the end of life, sometimes doing less is actually more. And if patients request less medical care, physicians should honor those desires.^4,5

Dr. Pantilat, the UCSF palliative-care expert, suggests asking open-ended questions to get at the heart of a patient’s wishes. For instance: “‘When you look to the future, what do you hope will happen?’ Or ‘When you think of life ahead, what worries you the most?’” The responses guide physicians in devising a plan of care that is consistent with a patient’s values. Having these discussions sooner rather than later is best for everyone involved, Dr. Pantilat says. Unfortunately, that’s not what usually happens.

About half of the more than 40% of Americans who die annually under hospice care do so within two weeks after being admitted. In such a short timeframe, even the most skilled experts are limited in what they can do, according to the National Hospice and Palliative Care Organization. To reverse this trend, Dr. Pantilat recommends that physicians consider making referrals to palliative care much earlier, whenever they sense that a patient may have a year or less to live.

Providing palliative care can be done in conjunction with life-prolonging therapies or as the central focus. The goal is to prevent and relieve suffering and to ensure the best possible quality of life for patients and their families, regardless of disease stage or the need for other treatments. Such care is suitable for patients with cancer, heart conditions, liver or renal failure, Alzheimer’s disease, spinal cord injuries, and a number of other illnesses, according to the National Consensus Project for Quality Palliative Care.

We have a lot of work to do to educate the public about the dying process. We are all going to die someday, and we all need to think about how and where we want to be when it happens, if we have any choice in it.

—Caitlin Foxley, MD, FHM, medical director, IMI Hospitalists, hospital service chief of internal medicine, Nebraska Medical Center, Omaha

Planning Ahead

In Arkansas, Dr. Wood typically turns to the hospital’s palliative-care team in end-of-life situations, asking its members to join in a conference with the patient and family. The team typically consists of a nurse, social worker and chaplain who can address various concerns. An employee from the medical billing department participates if necessary.

“Physicians should never assume that they understand the healthcare system, because it’s incredibly complicated,” Dr. Wood says, adding that she doesn’t pretend to be an expert in Medicare, Medicaid, or private insurance reimbursement issues.

Helping patients with advanced care planning can minimize difficulties later. Most patients who die in hospitals are admitted with end-stage disease, and most spend time in the ICU with mechanical ventilation. Physicians often are unaware of patients’ preferences, and this could lead to misunderstandings, especially in the ICU setting, where prognoses can shift quickly. One study showed that, in order for some of these patients to die, clinicians and families generally had to decide explicitly to strive toward less-than-completely-aggressive care.¹

“We’re trying to make sure that patients and families have an opportunity to do advanced-care planning,” Dr. Curtis says. Talking with them about their values and goals is essential for clinicians to understand their preferences.

Part of this involves crafting advanced-care directives. One such directive would be a power of attorney for healthcare, in which a patient states who is authorized to make decisions if he or she becomes unable to do so. This is particularly important for patients who select someone other than whom their state’s law would normally designate.

Another document—the living will—allows patients to specify their own preferences for end-of-life care. Yet “it’s often very difficult to know exactly what decisions will need to be made,” Dr. Curtis says. “Those documents are rarely determinative.” Even when a patient stipulates his or her wishes against “extraordinary life-sustaining measures, it still leaves a lot for interpretation.”

Some patients may spell out more clearly whether they wouldn’t want tube-feeding, CPR, or ventilation. This can be prescribed in written and signed Physician Orders for Life-Sustaining Treatment (POLST).

If you try to prognosticate a specific length of time, you will be wrong. You can give patients a lot of useful information by speaking in ranges.

—Steven Z. Pantilat, MD, FACP, professor of clinical medicine, director of the palliative-care program, University of California San Francisco Medical Center

Educating the Public

End-of-life discussions also pose a threat of litigation. “It takes a significant amount of time, often during a very busy day, to sit down with a patient and family members to bring up an issue that will undoubtedly raise many questions, some of which are impossible to answer,” says Dr. Foxley, the hospitalist service chief in Omaha. “I’m sure many physicians are uncomfortable with the tears that are shed.”

When Dr. Foxley recently advised a patient’s family that aggressive care would be futile, they directed their anger toward her. Their loved one died, despite the intensive treatment. It’s just one example of many in which Dr. Foxley has witnessed how high-tech medical treatments can incur astronomical hospital bills after just a few days while doing little—if anything—helpful for the patient.

“We have a lot of work to do to educate the public about the dying process,” she says, adding that the entire burden shouldn’t fall on physicians, and that patients should inform family members of their end-of-life wishes. “We are all going to die someday, and we all need to think about how and where we want to be when it happens, if we have any choice in it.”

Susan Kreimer is a freelance medical writer based in New York.

Helpful End-of-Life Prediction Tools

APACHE II (Acute Physiology and Chronic Health Evaluation II)

A severity-of-disease classification system and one of several ICU scoring systems, it is applied within 24 hours of patient admission. An integer score from 0 to 71 is computed based on several measurements; higher scores correspond to more severe disease and a higher risk of death. http://clincalc.com/IcuMortality/APACHEII.aspx

SOFA (Sequential Organ Failure Assessment)

SOFA tracks a patient’s status during an ICU stay. This scoring system determines the extent of a person’s organ function or rate of failure. The overall score is based on scores of the respiratory, cardiovascular, hepatic, coagulation, renal, and neurological systems. http://www.sfar.org/scores2/sofa2.html

The Karnofsky Performance Scale Index

This tool allows patients to be classified by functional impairment. It compares effectiveness of different therapies and assesses the prognosis in individual patients. The lower the Karnofsky score, the worse the survival outlook for most serious illnesses. http://www.hospicepatients.org/karnofsky.html

PPS (Palliative Performance Scale) 

First introduced in 1996 as a tool for performance status in palliative care, the PPS uses five observer-rated domains correlated to the Karnofsky index (100-0). PPS is used in many countries and is translated into many languages. http://supportforhome.wordpress.com/2011/06/15/palliative-performance-scale/

The BODE Index

BODE helps predict mortality from chronic obstructive pulmonary disease (COPD) after diagnosis. Presumably, a higher BODE score correlates with an increased risk of death. http://copd.about.com/od/copdbasics/a/BODEIndex.htm

The Charlson Comorbidity Index

This index predicts the 10-year mortality for a patient who might have a range of comorbid conditions, such as heart disease, AIDS, or cancer (a total of 22 conditions). Each condition is assigned a score, depending on the risk of dying associated with the condition. http://www.medal.org/OnlineCalculators/ch1/ch1.13/ch1.13.01.php

Hemodialysis Mortality Predictor

This online calculator estimates prognosis in end-stage renal disease patients using an integrated model that incorporates the patient age, serum albumin, comorbidities, and clinician assessment of the patient’s likelihood of being dead within a year. http://touchcalc.com/calculators/sq

—Susan Kreimer

References

1. Walling AM, Asch SM, Lorenz KA, et al. The quality of care provided to hospitalized patients at the end of life. Arch Intern Med. 2010;170(12):1057-1063.
2. Yourman LC, Lee SJ, Schonberg MA, Widera EW, Smith AK. Prognostic indices for older adults: a systematic review. JAMA. 2012;307(2):182-192.
3. Grudzen C, Grady D. Improving care at the end of life. Arch Intern Med. 2011;171(13):1202.
4. Grudzen C. At the end of life, sometimes less is more. Arch Intern Med. 2011;171(13):1201.
5. Bale PW. Honoring patients’ wishes for less health care. Arch Intern Med. 2011;171(13):1200.

Quotes from the Field

We cannot rely solely on a tool to make decisions. The tool is a decision aid.

Alvin H. Moss, MD, FAAHPM

Professor of medicine in the nephrology section and director of the Center for Health Ethics and Law at West Virginia University School of Medicine in Morgantown

 

Predictions really apply to groups of people, not individuals.

J. Randall Curtis, MD, MPH

Professor and section head in the division of pulmonary and critical care medicine at the University of Washington’s Harborview Medical Center in Seattle

 

if you ask a physician to provide you with his or her impression of a patient progression, we generally tend to overestimate how well they’re doing.

JoAnn Wood, MD, MSEd, MHA

Hospitalist and division director of general internal medicine at the University of Arkansas for Medical Sciences in Little Rock

 

Patients feel that you’re almost abandoning them, that there’s something you’re withholding.

Ann Sheehy

Director of the hospitalist service at University of Wisconsin Medical Center in Madison

 

Telling patients there is a 20% chance that they might die in the next year isn’t usually enough to change their thinking.

David Casarett, MD, MA

Associate professor of medicine at the University of Pennsylvania and chief medical officer of Penn-Wissahickon Hospice in Philadelphia

End-of-life conversations are common in hospital medicine, and Caitlin Foxley, MD, FHM, is no stranger to their nuance. She offers patients and loved ones as much factual information as she can. And regardless of their preference—aggressive treatment, comfort care, something in between—it’s ultimately their choice, not hers. But no matter what, she will ensure the patient’s pain remains under control.

“The way I practice is to allow my patients to make the end-of-life decision that is in accordance with their wishes, and not simply push the least expensive one on them,” says Dr. Foxley, medical director of IMI Hospitalists and hospital service chief of internal medicine at Nebraska Medical Center in Omaha. However, she adds, “most people, given accurate information in a compassionate manner, would choose to die at home, and not in an ICU on a ventilator, with chemo and pressers going through a central line.”

Although hospitalists differ in their approaches to end-of-life discussions, most agree that the majority of critically ill patients want to know their prognosis. Tested end-of-life prediction tools can help physicians provide realistic ranges for patients and families (see “Helpful End-of-Life Prediction Tools,” p. 39). Armed with this insight, they can hope to deliver better and more cost-effective end-of-life care.

Nonetheless, “we cannot rely solely on a tool to make decisions,” says Alvin H. Moss, MD, FAAHPM, professor of medicine in the nephrology section and director of the Center for Health Ethics and Law at West Virginia University School of Medicine in Morgantown. “The tool is a decision aid.”

Clinicians still need to help patients and families identify their treatment goals while determining which life-sustaining options they would or wouldn’t want to pursue, Dr. Moss says. That conversation would include an estimated prognosis of survival.

“If you try to prognosticate a specific length of time, you will be wrong,” says Steven Z. Pantilat, MD, FACP, SFHM, professor of clinical medicine and director of the palliative care program at the University of California San Francisco Medical Center. “You can give patients a lot of useful information by speaking in ranges.”

But it’s important to also convey the inherent uncertainty of any prognosis, considering that a very sick patient might suffer a sudden decline. For this reason, even the best prognostic indicators aren’t exact, Dr. Pantilat cautions. A prediction tool could forecast a 20% chance of six-month survival on the day before a patient’s death in the ICU.

“Predictions really apply to groups of people, not individuals,” says J. Randall Curtis, MD, MPH, professor and section head in the division of pulmonary and critical care medicine at the University of Washington’s Harborview Medical Center in Seattle. Physicians can’t possibly know whether someone will fall into the 95% of patients who die or the 5% of patients who beat the odds.

“It’s never certain that a patient is not going to survive,” says Dr. Curtis, who is director of the Harborview/University of Washington End-of-Life Care Research Program. While patients are less likely to request aggressive care in light of a poor prognosis, some will elect intensive treatment in hopes of defying even the grimmest statistics.

More Medical Tests and Procedures

In the U.S., it’s much more common for patients to receive life-saving treatments than in other countries. The expectation is that expensive medical technology can always prolong life.¹

“A lot of patients have that mentality,” says Ann Sheehy, MD, MS, director of the hospitalist service at University of Wisconsin Medical Center in Madison. “That makes it harder to have the discussion with patients that there isn’t something else we can do.” Patients feel “that you’re almost abandoning them, that there’s something you’re withholding.”

The widespread assumption that more medical tests and procedures lead to better outcomes goes hand in hand with the misperception that sufficiently controlling pain and other symptoms draws death closer. As a result, many patients end up dying with distressing symptoms in the hospital instead of peacefully at home.¹

As physicians, Dr. Sheehy points out, “We don’t do a good job of saying, ‘This care probably is not going to help you or that it will leave you with a very bad quality of life in the end.’” But projections are far from perfect.

“Telling patients there is a 20% chance that they might die in the next year isn’t usually enough to change their thinking. Nor is it enough to justify withholding treatment,” says David Casarett, MD, MA, associate professor of medicine at the University of Pennsylvania and chief medical officer of Penn-Wissahickon Hospice in Philadelphia.

What prognostic information can do is play an important part in guiding appropriate screening and preventive health measures. For example, if a male patient has a 50% chance of dying within four years, it doesn’t make sense to screen for prostate cancer, a slow-growing malignancy that often takes years to develop. This protocol may also apply to cancer screenings, as well as treatments for diabetes, high blood pressure, or high cholesterol, Dr. Casarett says. 

End-of-Life Conversations

By not taking a patient’s prognosis into account, many clinical decisions are not fully informed. In physicians’ clinical practice and training, there tends to be less emphasis on estimating prognosis than on diagnosing and treating illness. This is particularly significant in older adults with competing chronic conditions and diminished life expectancy.²

“Many physicians have not been trained in how to have these conversations, which is something we’re trying to change,” says Dr. Curtis, the pulmonary and critical care specialist at the University of Washington. “This is very emotionally difficult for patients and families, and therefore, it can also be emotionally difficult for physicians.”

Starting this summer, medical residents at Cooper University Hospital in Camden, N.J., will have mandated exposure to palliative care. The rotation, lasting from two to four weeks, will occur in their second year of training, says Mark Angelo, MD, FACP, director of palliative medicine.

Residents will accompany the palliative-care team for an intensive period of time to learn about different techniques for symptom control and to observe end-of-life conversations, which often elicit patients’ angst, depression, and physiologic and spiritual unrest.

“We already have residents rotating with us now in the palliative-care program, and everybody is very struck by how honest patients want you to be,” Dr. Angelo says. “It certainly is devastating, and we understand that. But it does give patients the opportunity to reorganize their lives and to prioritize a number of issues, including medical treatment.”

Some patients opt to spend more time with their grandchildren rather than stay in the hospital. Others prefer to eat and drink whatever they want. Many terminally ill Hispanic patients in the Camden area travel to Latin America, where they were born, or they invite relatives to visit them here, Dr. Angelo says.

While it’s difficult to accept finality, “there’s a certain amount of freedom that comes with that,” he says. “If someone has a prognosis of two months, they may make very different decisions than someone who has a prognosis of two years.”

Physicians tend to be overly optimistic, notes JoAnn Wood, MD, MSEd, MHA, a hospitalist and division director of general internal medicine at the University of Arkansas for Medical Sciences in Little Rock. “The data suggest that, if you ask a physician to provide you with his or her impression of a patient progression, we generally tend to overestimate how well they’re doing,” particularly with cancer patients, Dr. Wood says. “Physicians don’t choose this line of work to facilitate people’s dying.”

When Doing Less Is More

End-of-life prediction tools enable clinicians to keep their expectations of a patient’s survival grounded in reality. And in many hospitals, palliative-care providers are available to lend their expertise. “The field of palliative medicine has taken a lot of strides,” Dr. Wood says, “in helping us to seeing that dying is something that can be done well, just like living can be done well.”

In fact, growing evidence indicates that treating a patient’s discomfort is linked to improvement in physical status and might even increase survival.³ What this means is that, at the end of life, sometimes doing less is actually more. And if patients request less medical care, physicians should honor those desires.^4,5

Dr. Pantilat, the UCSF palliative-care expert, suggests asking open-ended questions to get at the heart of a patient’s wishes. For instance: “‘When you look to the future, what do you hope will happen?’ Or ‘When you think of life ahead, what worries you the most?’” The responses guide physicians in devising a plan of care that is consistent with a patient’s values. Having these discussions sooner rather than later is best for everyone involved, Dr. Pantilat says. Unfortunately, that’s not what usually happens.

About half of the more than 40% of Americans who die annually under hospice care do so within two weeks after being admitted. In such a short timeframe, even the most skilled experts are limited in what they can do, according to the National Hospice and Palliative Care Organization. To reverse this trend, Dr. Pantilat recommends that physicians consider making referrals to palliative care much earlier, whenever they sense that a patient may have a year or less to live.

Providing palliative care can be done in conjunction with life-prolonging therapies or as the central focus. The goal is to prevent and relieve suffering and to ensure the best possible quality of life for patients and their families, regardless of disease stage or the need for other treatments. Such care is suitable for patients with cancer, heart conditions, liver or renal failure, Alzheimer’s disease, spinal cord injuries, and a number of other illnesses, according to the National Consensus Project for Quality Palliative Care.

We have a lot of work to do to educate the public about the dying process. We are all going to die someday, and we all need to think about how and where we want to be when it happens, if we have any choice in it.

—Caitlin Foxley, MD, FHM, medical director, IMI Hospitalists, hospital service chief of internal medicine, Nebraska Medical Center, Omaha

Planning Ahead

In Arkansas, Dr. Wood typically turns to the hospital’s palliative-care team in end-of-life situations, asking its members to join in a conference with the patient and family. The team typically consists of a nurse, social worker and chaplain who can address various concerns. An employee from the medical billing department participates if necessary.

“Physicians should never assume that they understand the healthcare system, because it’s incredibly complicated,” Dr. Wood says, adding that she doesn’t pretend to be an expert in Medicare, Medicaid, or private insurance reimbursement issues.

Helping patients with advanced care planning can minimize difficulties later. Most patients who die in hospitals are admitted with end-stage disease, and most spend time in the ICU with mechanical ventilation. Physicians often are unaware of patients’ preferences, and this could lead to misunderstandings, especially in the ICU setting, where prognoses can shift quickly. One study showed that, in order for some of these patients to die, clinicians and families generally had to decide explicitly to strive toward less-than-completely-aggressive care.¹

“We’re trying to make sure that patients and families have an opportunity to do advanced-care planning,” Dr. Curtis says. Talking with them about their values and goals is essential for clinicians to understand their preferences.

Part of this involves crafting advanced-care directives. One such directive would be a power of attorney for healthcare, in which a patient states who is authorized to make decisions if he or she becomes unable to do so. This is particularly important for patients who select someone other than whom their state’s law would normally designate.

Another document—the living will—allows patients to specify their own preferences for end-of-life care. Yet “it’s often very difficult to know exactly what decisions will need to be made,” Dr. Curtis says. “Those documents are rarely determinative.” Even when a patient stipulates his or her wishes against “extraordinary life-sustaining measures, it still leaves a lot for interpretation.”

Some patients may spell out more clearly whether they wouldn’t want tube-feeding, CPR, or ventilation. This can be prescribed in written and signed Physician Orders for Life-Sustaining Treatment (POLST).

If you try to prognosticate a specific length of time, you will be wrong. You can give patients a lot of useful information by speaking in ranges.

—Steven Z. Pantilat, MD, FACP, professor of clinical medicine, director of the palliative-care program, University of California San Francisco Medical Center

Educating the Public

End-of-life discussions also pose a threat of litigation. “It takes a significant amount of time, often during a very busy day, to sit down with a patient and family members to bring up an issue that will undoubtedly raise many questions, some of which are impossible to answer,” says Dr. Foxley, the hospitalist service chief in Omaha. “I’m sure many physicians are uncomfortable with the tears that are shed.”

When Dr. Foxley recently advised a patient’s family that aggressive care would be futile, they directed their anger toward her. Their loved one died, despite the intensive treatment. It’s just one example of many in which Dr. Foxley has witnessed how high-tech medical treatments can incur astronomical hospital bills after just a few days while doing little—if anything—helpful for the patient.

“We have a lot of work to do to educate the public about the dying process,” she says, adding that the entire burden shouldn’t fall on physicians, and that patients should inform family members of their end-of-life wishes. “We are all going to die someday, and we all need to think about how and where we want to be when it happens, if we have any choice in it.”

Susan Kreimer is a freelance medical writer based in New York.

Helpful End-of-Life Prediction Tools

APACHE II (Acute Physiology and Chronic Health Evaluation II)

A severity-of-disease classification system and one of several ICU scoring systems, it is applied within 24 hours of patient admission. An integer score from 0 to 71 is computed based on several measurements; higher scores correspond to more severe disease and a higher risk of death. http://clincalc.com/IcuMortality/APACHEII.aspx

SOFA (Sequential Organ Failure Assessment)

SOFA tracks a patient’s status during an ICU stay. This scoring system determines the extent of a person’s organ function or rate of failure. The overall score is based on scores of the respiratory, cardiovascular, hepatic, coagulation, renal, and neurological systems. http://www.sfar.org/scores2/sofa2.html

The Karnofsky Performance Scale Index

This tool allows patients to be classified by functional impairment. It compares effectiveness of different therapies and assesses the prognosis in individual patients. The lower the Karnofsky score, the worse the survival outlook for most serious illnesses. http://www.hospicepatients.org/karnofsky.html

PPS (Palliative Performance Scale) 

First introduced in 1996 as a tool for performance status in palliative care, the PPS uses five observer-rated domains correlated to the Karnofsky index (100-0). PPS is used in many countries and is translated into many languages. http://supportforhome.wordpress.com/2011/06/15/palliative-performance-scale/

The BODE Index

BODE helps predict mortality from chronic obstructive pulmonary disease (COPD) after diagnosis. Presumably, a higher BODE score correlates with an increased risk of death. http://copd.about.com/od/copdbasics/a/BODEIndex.htm

The Charlson Comorbidity Index

This index predicts the 10-year mortality for a patient who might have a range of comorbid conditions, such as heart disease, AIDS, or cancer (a total of 22 conditions). Each condition is assigned a score, depending on the risk of dying associated with the condition. http://www.medal.org/OnlineCalculators/ch1/ch1.13/ch1.13.01.php

Hemodialysis Mortality Predictor

This online calculator estimates prognosis in end-stage renal disease patients using an integrated model that incorporates the patient age, serum albumin, comorbidities, and clinician assessment of the patient’s likelihood of being dead within a year. http://touchcalc.com/calculators/sq

—Susan Kreimer

References

1. Walling AM, Asch SM, Lorenz KA, et al. The quality of care provided to hospitalized patients at the end of life. Arch Intern Med. 2010;170(12):1057-1063.
2. Yourman LC, Lee SJ, Schonberg MA, Widera EW, Smith AK. Prognostic indices for older adults: a systematic review. JAMA. 2012;307(2):182-192.
3. Grudzen C, Grady D. Improving care at the end of life. Arch Intern Med. 2011;171(13):1202.
4. Grudzen C. At the end of life, sometimes less is more. Arch Intern Med. 2011;171(13):1201.
5. Bale PW. Honoring patients’ wishes for less health care. Arch Intern Med. 2011;171(13):1200.