Peter Pronovost, MD, PhD, an intensivist and patient-safety researcher at Johns Hopkins University School of Medicine in Baltimore, has been widely profiled as the “checklist doctor” for his celebrated five-step checklist to reduce the incidence of central-line infections. But he objects to the label.

Just handing doctors and nurses a piece of paper is not likely to improve patient safety without two other essential steps: “We must also measure the results and give clinicians feedback, and we must change the culture so that they work collaboratively together,” he explains.

Dr. Pronovost shares his personal story as a safety expert who borrowed from aviation in developing his first checklist in 2001 in a Johns Hopkins surgical ICU in his new book, Safe Patients, Smart Hospitals, co-authored with Eric Vohr (New York: Hudson Street Press, 2010).

Dr. Pronovost says he still encounters resistance to the checklist in many U.S. hospitals. “Nobody debates that we should be doing the things on the checklist,” he says. “The evidence is strong. The barrier is culture or medical hierarchy. In what other industry would there be an accepted standard that failure to comply with it kills, in this case, 30,000 people per year, and yet we’re not comfortable having one worker question another about compliance with it?”

Hospitalists have a huge role in hospital quality and safety, he adds.

“I envision that they could take almost any practice guideline that’s out there and convert it into a checklist,” he says, emphasizing that hospitalists should appoint an interdisciplinary team to work on the project and make the checklists specific to one time and place. It also is important for hospitals to support hospitalists with dedicated time to work on such projects. “But in return, the hospitalists have to commit measuring safety performance and producing positive results,” he says.

Peter Pronovost, MD, PhD, an intensivist and patient-safety researcher at Johns Hopkins University School of Medicine in Baltimore, has been widely profiled as the “checklist doctor” for his celebrated five-step checklist to reduce the incidence of central-line infections. But he objects to the label.

Just handing doctors and nurses a piece of paper is not likely to improve patient safety without two other essential steps: “We must also measure the results and give clinicians feedback, and we must change the culture so that they work collaboratively together,” he explains.

Dr. Pronovost shares his personal story as a safety expert who borrowed from aviation in developing his first checklist in 2001 in a Johns Hopkins surgical ICU in his new book, Safe Patients, Smart Hospitals, co-authored with Eric Vohr (New York: Hudson Street Press, 2010).

Dr. Pronovost says he still encounters resistance to the checklist in many U.S. hospitals. “Nobody debates that we should be doing the things on the checklist,” he says. “The evidence is strong. The barrier is culture or medical hierarchy. In what other industry would there be an accepted standard that failure to comply with it kills, in this case, 30,000 people per year, and yet we’re not comfortable having one worker question another about compliance with it?”

Hospitalists have a huge role in hospital quality and safety, he adds.

“I envision that they could take almost any practice guideline that’s out there and convert it into a checklist,” he says, emphasizing that hospitalists should appoint an interdisciplinary team to work on the project and make the checklists specific to one time and place. It also is important for hospitals to support hospitalists with dedicated time to work on such projects. “But in return, the hospitalists have to commit measuring safety performance and producing positive results,” he says.

Peter Pronovost, MD, PhD, an intensivist and patient-safety researcher at Johns Hopkins University School of Medicine in Baltimore, has been widely profiled as the “checklist doctor” for his celebrated five-step checklist to reduce the incidence of central-line infections. But he objects to the label.

Just handing doctors and nurses a piece of paper is not likely to improve patient safety without two other essential steps: “We must also measure the results and give clinicians feedback, and we must change the culture so that they work collaboratively together,” he explains.

Dr. Pronovost shares his personal story as a safety expert who borrowed from aviation in developing his first checklist in 2001 in a Johns Hopkins surgical ICU in his new book, Safe Patients, Smart Hospitals, co-authored with Eric Vohr (New York: Hudson Street Press, 2010).

Dr. Pronovost says he still encounters resistance to the checklist in many U.S. hospitals. “Nobody debates that we should be doing the things on the checklist,” he says. “The evidence is strong. The barrier is culture or medical hierarchy. In what other industry would there be an accepted standard that failure to comply with it kills, in this case, 30,000 people per year, and yet we’re not comfortable having one worker question another about compliance with it?”

Hospitalists have a huge role in hospital quality and safety, he adds.

“I envision that they could take almost any practice guideline that’s out there and convert it into a checklist,” he says, emphasizing that hospitalists should appoint an interdisciplinary team to work on the project and make the checklists specific to one time and place. It also is important for hospitals to support hospitalists with dedicated time to work on such projects. “But in return, the hospitalists have to commit measuring safety performance and producing positive results,” he says.

An author of a recent study that found improved results for depressed alcohol-dependent patients when they were treated for both diagnoses says hospitalists are positioned to help push increased usage of the dual-medication approach.

“This could change the way people treat these patients,” says first author Helen Pettinati, PhD, professor of psychiatry and director of the Addiction Treatment & Medication Development Division at the University of Pennsylvania School of Medicine’s Treatment Research Center in Philadelphia.

The study in the American Journal of Psychiatry tracked 170 patients, with some treated with 14 weeks of sertraline (200 mg/day, n=40), naltrexone (100 mg/day, n=49), both drugs (n=42), or double placebo (n=39). All groups received weekly counseling as well. Patients treated with both medications produced a higher alcohol abstinence rate (53.7%) and demonstrated a longer delay before relapse to heavy drinking (median delay=98 days) than the naltrexone (abstinence rate: 21.3%; delay=29 days), sertraline (abstinence rate: 27.5%; delay=23 days), and placebo (abstinence rate: 23.1%; delay=26 days) groups. In addition, patients treated with both medications “reported fewer serious adverse events, and tended to not be depressed by the end of treatment,” the authors wrote.

Pettinati says it is uncommon for hospitalists and other physicians to consider treating hospitalized patients with medication for alcohol dependence. She hopes hospitalists see this study as a spotlight on that approach. In past years, Pettinati suggests, medication for alcohol dependence might have been viewed as unnecessary because patient lengths-of-stay (LOS) were longer. Today, HM leaders are pushing for ever-shorter LOS.

“Now when a person comes in,” Pettinati says, “you have to make an immediate decision what kind of medication you want to treat this person with.”

An author of a recent study that found improved results for depressed alcohol-dependent patients when they were treated for both diagnoses says hospitalists are positioned to help push increased usage of the dual-medication approach.

“This could change the way people treat these patients,” says first author Helen Pettinati, PhD, professor of psychiatry and director of the Addiction Treatment & Medication Development Division at the University of Pennsylvania School of Medicine’s Treatment Research Center in Philadelphia.

The study in the American Journal of Psychiatry tracked 170 patients, with some treated with 14 weeks of sertraline (200 mg/day, n=40), naltrexone (100 mg/day, n=49), both drugs (n=42), or double placebo (n=39). All groups received weekly counseling as well. Patients treated with both medications produced a higher alcohol abstinence rate (53.7%) and demonstrated a longer delay before relapse to heavy drinking (median delay=98 days) than the naltrexone (abstinence rate: 21.3%; delay=29 days), sertraline (abstinence rate: 27.5%; delay=23 days), and placebo (abstinence rate: 23.1%; delay=26 days) groups. In addition, patients treated with both medications “reported fewer serious adverse events, and tended to not be depressed by the end of treatment,” the authors wrote.

Pettinati says it is uncommon for hospitalists and other physicians to consider treating hospitalized patients with medication for alcohol dependence. She hopes hospitalists see this study as a spotlight on that approach. In past years, Pettinati suggests, medication for alcohol dependence might have been viewed as unnecessary because patient lengths-of-stay (LOS) were longer. Today, HM leaders are pushing for ever-shorter LOS.

“Now when a person comes in,” Pettinati says, “you have to make an immediate decision what kind of medication you want to treat this person with.”

An author of a recent study that found improved results for depressed alcohol-dependent patients when they were treated for both diagnoses says hospitalists are positioned to help push increased usage of the dual-medication approach.

“This could change the way people treat these patients,” says first author Helen Pettinati, PhD, professor of psychiatry and director of the Addiction Treatment & Medication Development Division at the University of Pennsylvania School of Medicine’s Treatment Research Center in Philadelphia.

The study in the American Journal of Psychiatry tracked 170 patients, with some treated with 14 weeks of sertraline (200 mg/day, n=40), naltrexone (100 mg/day, n=49), both drugs (n=42), or double placebo (n=39). All groups received weekly counseling as well. Patients treated with both medications produced a higher alcohol abstinence rate (53.7%) and demonstrated a longer delay before relapse to heavy drinking (median delay=98 days) than the naltrexone (abstinence rate: 21.3%; delay=29 days), sertraline (abstinence rate: 27.5%; delay=23 days), and placebo (abstinence rate: 23.1%; delay=26 days) groups. In addition, patients treated with both medications “reported fewer serious adverse events, and tended to not be depressed by the end of treatment,” the authors wrote.

Pettinati says it is uncommon for hospitalists and other physicians to consider treating hospitalized patients with medication for alcohol dependence. She hopes hospitalists see this study as a spotlight on that approach. In past years, Pettinati suggests, medication for alcohol dependence might have been viewed as unnecessary because patient lengths-of-stay (LOS) were longer. Today, HM leaders are pushing for ever-shorter LOS.

“Now when a person comes in,” Pettinati says, “you have to make an immediate decision what kind of medication you want to treat this person with.”

A recent study that associates lower 30-day readmission rates for heart failure patients who receive followups within one week might be a jumpstart to new incentives for fewer readmissions, says the report’s author.

“In a way, [hospitalists] are central to all this,” says Adrian F. Hernandez, MD, MHS, an assistant professor at Duke University School of Medicine and a cardiologist at Duke University Medical Center in Durham, N.C. “During the hospital stay, they are quarterbacking that patient’s care. They have a central responsibility to make sure that patient discharge is seamless.”

The study tracked 30,136 patients who were seen at 225 hospitals from January 2003 to December 2006. It reported that in the first 30 days after discharge, 6,428 patients (21.3 percent) were readmitted (JAMA. 2010;303(17):1716-1722).

At the hospital level, the median rate of early followup was 38.3 percent. According to the study, patients whose index admission was in a hospital in the lowest quartile of early followup had a 23.3% 30-day readmission rate. The rates of 30-day readmission were 20.5% among patients in the second quartile, 20.5% among patients in the third quartile, and 20.9% among patients in the fourth quartile.

Dr. Hernandez says the next step is for hospitals and their staffs to commit to more streamlined transitional-care techniques that include immediate followup with patients, be it via teleconferencing with doctors or phone calls with nonphysician providers (NPPs) or clinical pharmacists. He adds that incentivizing doctors to reduce readmissions is a logical next step to improving the discharge process.

“Now that 30-day readmissions are publicly reported and hospitals are being held accountable for that, they need to invest in systems that will enhance that transitional period,” Dr. Hernandez says.

A recent study that associates lower 30-day readmission rates for heart failure patients who receive followups within one week might be a jumpstart to new incentives for fewer readmissions, says the report’s author.

“In a way, [hospitalists] are central to all this,” says Adrian F. Hernandez, MD, MHS, an assistant professor at Duke University School of Medicine and a cardiologist at Duke University Medical Center in Durham, N.C. “During the hospital stay, they are quarterbacking that patient’s care. They have a central responsibility to make sure that patient discharge is seamless.”

The study tracked 30,136 patients who were seen at 225 hospitals from January 2003 to December 2006. It reported that in the first 30 days after discharge, 6,428 patients (21.3 percent) were readmitted (JAMA. 2010;303(17):1716-1722).

At the hospital level, the median rate of early followup was 38.3 percent. According to the study, patients whose index admission was in a hospital in the lowest quartile of early followup had a 23.3% 30-day readmission rate. The rates of 30-day readmission were 20.5% among patients in the second quartile, 20.5% among patients in the third quartile, and 20.9% among patients in the fourth quartile.

Dr. Hernandez says the next step is for hospitals and their staffs to commit to more streamlined transitional-care techniques that include immediate followup with patients, be it via teleconferencing with doctors or phone calls with nonphysician providers (NPPs) or clinical pharmacists. He adds that incentivizing doctors to reduce readmissions is a logical next step to improving the discharge process.

“Now that 30-day readmissions are publicly reported and hospitals are being held accountable for that, they need to invest in systems that will enhance that transitional period,” Dr. Hernandez says.

A recent study that associates lower 30-day readmission rates for heart failure patients who receive followups within one week might be a jumpstart to new incentives for fewer readmissions, says the report’s author.

“In a way, [hospitalists] are central to all this,” says Adrian F. Hernandez, MD, MHS, an assistant professor at Duke University School of Medicine and a cardiologist at Duke University Medical Center in Durham, N.C. “During the hospital stay, they are quarterbacking that patient’s care. They have a central responsibility to make sure that patient discharge is seamless.”

The study tracked 30,136 patients who were seen at 225 hospitals from January 2003 to December 2006. It reported that in the first 30 days after discharge, 6,428 patients (21.3 percent) were readmitted (JAMA. 2010;303(17):1716-1722).

At the hospital level, the median rate of early followup was 38.3 percent. According to the study, patients whose index admission was in a hospital in the lowest quartile of early followup had a 23.3% 30-day readmission rate. The rates of 30-day readmission were 20.5% among patients in the second quartile, 20.5% among patients in the third quartile, and 20.9% among patients in the fourth quartile.

Dr. Hernandez says the next step is for hospitals and their staffs to commit to more streamlined transitional-care techniques that include immediate followup with patients, be it via teleconferencing with doctors or phone calls with nonphysician providers (NPPs) or clinical pharmacists. He adds that incentivizing doctors to reduce readmissions is a logical next step to improving the discharge process.

“Now that 30-day readmissions are publicly reported and hospitals are being held accountable for that, they need to invest in systems that will enhance that transitional period,” Dr. Hernandez says.

Clinical question: Do rapid-response teams (RRTs) reduce the rates of cardiopulmonary arrest and hospital mortality?

Background: RRTs are charged with prompt evaluation and treatment of inpatients with clinical deterioration to prevent cardiopulmonary arrest and its attendant mortality. Though hundreds of hospitals have implemented these teams as part of their quality-improvement (QI) initiatives, previous studies on RRTs have reported mixed results on the clinically meaningful outcome of hospital mortality.

Study design: Meta-analysis and systematic review.

Setting: Randomized, controlled trials and prospective studies on RRTs from multiple databases, including PubMed, EMBASE, and CINAHL.

Synopsis: Eighteen studies (13 adult and five pediatric) with a total sample size of nearly 1.3 million admissions were analyzed. Of these, 15 reported on the primary outcome of in-hospital mortality; 16 reported on the secondary outcome of cardiopulmonary arrest. All of the studies exhibited extensive heterogeneity of outcomes, but six studies were deemed to be of high quality.

In adults, RRT implementation reduced non-ICU cardiopulmonary arrest by 33.8%, without an effect on hospital mortality (pooled RR, 0.96; 95% CI, 0.84-1.09). Interestingly, the inclusion of recent evidence neutralized positive results from initial studies in the overall pooled analysis.

In children, apart from reduction in arrest (37.7%), a weak association with lower mortality rates (pooled RR, 0.79; 95% CI, 0.63-0.98) was noticed. This did not hold on sensitivity analysis, but that could be explained by their higher likelihood to survive cardiac arrest than adults.

The discordance between the primary and secondary outcomes could be due to pre-arrest transfer to ICU or establishment of DNR status by RRT, hence excluding them from mortality analysis.

Bottom line: Although RRTs reduce rates of cardiopulmonary arrest outside the ICU, no consistent evidence shows RRTs improve survival to discharge.

Citation: Chan PS, Jain R, Nallmothu BK, Berg RA, Sasson C. Rapid response teams: a systematic review and meta-analysis. Arch Intern Med. 2010;170(1):18-26.

Reviewed for TH eWire by Rubin Bahuva, MD, Chadi Alraies, MD, Anuradha Ramaswamy, MD, Sudhir Manda, MD, Maria Giselle Velez, MD, and Mital Patel, MD, Department of Hospital Medicine, Cleveland Clinic

For more physician reviews of HM-related research, visit our website.

Clinical question: Do rapid-response teams (RRTs) reduce the rates of cardiopulmonary arrest and hospital mortality?

Background: RRTs are charged with prompt evaluation and treatment of inpatients with clinical deterioration to prevent cardiopulmonary arrest and its attendant mortality. Though hundreds of hospitals have implemented these teams as part of their quality-improvement (QI) initiatives, previous studies on RRTs have reported mixed results on the clinically meaningful outcome of hospital mortality.

Study design: Meta-analysis and systematic review.

Setting: Randomized, controlled trials and prospective studies on RRTs from multiple databases, including PubMed, EMBASE, and CINAHL.

Synopsis: Eighteen studies (13 adult and five pediatric) with a total sample size of nearly 1.3 million admissions were analyzed. Of these, 15 reported on the primary outcome of in-hospital mortality; 16 reported on the secondary outcome of cardiopulmonary arrest. All of the studies exhibited extensive heterogeneity of outcomes, but six studies were deemed to be of high quality.

In adults, RRT implementation reduced non-ICU cardiopulmonary arrest by 33.8%, without an effect on hospital mortality (pooled RR, 0.96; 95% CI, 0.84-1.09). Interestingly, the inclusion of recent evidence neutralized positive results from initial studies in the overall pooled analysis.

In children, apart from reduction in arrest (37.7%), a weak association with lower mortality rates (pooled RR, 0.79; 95% CI, 0.63-0.98) was noticed. This did not hold on sensitivity analysis, but that could be explained by their higher likelihood to survive cardiac arrest than adults.

The discordance between the primary and secondary outcomes could be due to pre-arrest transfer to ICU or establishment of DNR status by RRT, hence excluding them from mortality analysis.

Bottom line: Although RRTs reduce rates of cardiopulmonary arrest outside the ICU, no consistent evidence shows RRTs improve survival to discharge.

Citation: Chan PS, Jain R, Nallmothu BK, Berg RA, Sasson C. Rapid response teams: a systematic review and meta-analysis. Arch Intern Med. 2010;170(1):18-26.

Reviewed for TH eWire by Rubin Bahuva, MD, Chadi Alraies, MD, Anuradha Ramaswamy, MD, Sudhir Manda, MD, Maria Giselle Velez, MD, and Mital Patel, MD, Department of Hospital Medicine, Cleveland Clinic

For more physician reviews of HM-related research, visit our website.

Clinical question: Do rapid-response teams (RRTs) reduce the rates of cardiopulmonary arrest and hospital mortality?

Background: RRTs are charged with prompt evaluation and treatment of inpatients with clinical deterioration to prevent cardiopulmonary arrest and its attendant mortality. Though hundreds of hospitals have implemented these teams as part of their quality-improvement (QI) initiatives, previous studies on RRTs have reported mixed results on the clinically meaningful outcome of hospital mortality.

Study design: Meta-analysis and systematic review.

Setting: Randomized, controlled trials and prospective studies on RRTs from multiple databases, including PubMed, EMBASE, and CINAHL.

Synopsis: Eighteen studies (13 adult and five pediatric) with a total sample size of nearly 1.3 million admissions were analyzed. Of these, 15 reported on the primary outcome of in-hospital mortality; 16 reported on the secondary outcome of cardiopulmonary arrest. All of the studies exhibited extensive heterogeneity of outcomes, but six studies were deemed to be of high quality.

In adults, RRT implementation reduced non-ICU cardiopulmonary arrest by 33.8%, without an effect on hospital mortality (pooled RR, 0.96; 95% CI, 0.84-1.09). Interestingly, the inclusion of recent evidence neutralized positive results from initial studies in the overall pooled analysis.

In children, apart from reduction in arrest (37.7%), a weak association with lower mortality rates (pooled RR, 0.79; 95% CI, 0.63-0.98) was noticed. This did not hold on sensitivity analysis, but that could be explained by their higher likelihood to survive cardiac arrest than adults.

The discordance between the primary and secondary outcomes could be due to pre-arrest transfer to ICU or establishment of DNR status by RRT, hence excluding them from mortality analysis.

Bottom line: Although RRTs reduce rates of cardiopulmonary arrest outside the ICU, no consistent evidence shows RRTs improve survival to discharge.

Citation: Chan PS, Jain R, Nallmothu BK, Berg RA, Sasson C. Rapid response teams: a systematic review and meta-analysis. Arch Intern Med. 2010;170(1):18-26.

Reviewed for TH eWire by Rubin Bahuva, MD, Chadi Alraies, MD, Anuradha Ramaswamy, MD, Sudhir Manda, MD, Maria Giselle Velez, MD, and Mital Patel, MD, Department of Hospital Medicine, Cleveland Clinic

For more physician reviews of HM-related research, visit our website.

The IRS has sided with medical residents and their employers who for years have argued that they should have always been eligible for the “student exemption”—but don’t count on any money just yet.

By mid-June, the IRS expects to have contacted hospitals, universities, and individual residents who filed Social Security and Medicare payroll tax refund claims as of April 1, 2005. The date is significant because it is when the IRS ruled that employees who work 40 hours or more at a school, college, or university are eligible for student exemptions.

The IRS’ administrative decision in early March affects taxes paid before 2005.

The IRS has only taken the first step and says instructions on how to further process claims will be forthcoming. For now, the federal agency says, “employers and individuals with pending claims do not need to take any action at this time.”

Still, Joseph Ming-Wah Li, MD, SFHM, assistant professor of medicine at Harvard Medical School and director of the hospital medicine division at Beth Israel Deaconess Medical Center in Boston, urges hospitalists to pay attention to the refund; over three years of residency, it could amount to several thousand dollars per physician.

“The government ruling recently was that residents should be treated more like students instead of employees,” says Dr. Li, SHM's president-elect.

Hospitals, medical schools, and residents themselves have been filing so-called “FICA refund claims” since the 1990s. A series of legal challenges led to opposing interpretations of tax codes, leading the IRS to suspend all claims until a ruling was made.

And while pending claims will now be processed, it is too late for new claims to be filed. However, residents who did not file individual claims in what the IRS calls a “timely fashion” should check with their residency institution to determine if a claim was filed on their behalf.

Read "Dr. Hospitalist's" take on this topic in this month's issue of The Hospitalist.

For more details, visit the IRS website.

The IRS has sided with medical residents and their employers who for years have argued that they should have always been eligible for the “student exemption”—but don’t count on any money just yet.

By mid-June, the IRS expects to have contacted hospitals, universities, and individual residents who filed Social Security and Medicare payroll tax refund claims as of April 1, 2005. The date is significant because it is when the IRS ruled that employees who work 40 hours or more at a school, college, or university are eligible for student exemptions.

The IRS’ administrative decision in early March affects taxes paid before 2005.

The IRS has only taken the first step and says instructions on how to further process claims will be forthcoming. For now, the federal agency says, “employers and individuals with pending claims do not need to take any action at this time.”

Still, Joseph Ming-Wah Li, MD, SFHM, assistant professor of medicine at Harvard Medical School and director of the hospital medicine division at Beth Israel Deaconess Medical Center in Boston, urges hospitalists to pay attention to the refund; over three years of residency, it could amount to several thousand dollars per physician.

“The government ruling recently was that residents should be treated more like students instead of employees,” says Dr. Li, SHM's president-elect.

Hospitals, medical schools, and residents themselves have been filing so-called “FICA refund claims” since the 1990s. A series of legal challenges led to opposing interpretations of tax codes, leading the IRS to suspend all claims until a ruling was made.

And while pending claims will now be processed, it is too late for new claims to be filed. However, residents who did not file individual claims in what the IRS calls a “timely fashion” should check with their residency institution to determine if a claim was filed on their behalf.

Read "Dr. Hospitalist's" take on this topic in this month's issue of The Hospitalist.

For more details, visit the IRS website.

The IRS has sided with medical residents and their employers who for years have argued that they should have always been eligible for the “student exemption”—but don’t count on any money just yet.

By mid-June, the IRS expects to have contacted hospitals, universities, and individual residents who filed Social Security and Medicare payroll tax refund claims as of April 1, 2005. The date is significant because it is when the IRS ruled that employees who work 40 hours or more at a school, college, or university are eligible for student exemptions.

The IRS’ administrative decision in early March affects taxes paid before 2005.

The IRS has only taken the first step and says instructions on how to further process claims will be forthcoming. For now, the federal agency says, “employers and individuals with pending claims do not need to take any action at this time.”

Still, Joseph Ming-Wah Li, MD, SFHM, assistant professor of medicine at Harvard Medical School and director of the hospital medicine division at Beth Israel Deaconess Medical Center in Boston, urges hospitalists to pay attention to the refund; over three years of residency, it could amount to several thousand dollars per physician.

“The government ruling recently was that residents should be treated more like students instead of employees,” says Dr. Li, SHM's president-elect.

Hospitals, medical schools, and residents themselves have been filing so-called “FICA refund claims” since the 1990s. A series of legal challenges led to opposing interpretations of tax codes, leading the IRS to suspend all claims until a ruling was made.

And while pending claims will now be processed, it is too late for new claims to be filed. However, residents who did not file individual claims in what the IRS calls a “timely fashion” should check with their residency institution to determine if a claim was filed on their behalf.

Read "Dr. Hospitalist's" take on this topic in this month's issue of The Hospitalist.

For more details, visit the IRS website.

Clinical question: Does remote ICU monitoring improve mortality and length of stay?

Background: A shortage of intensivists has led to increased use of remote ICU monitoring or telemedicine technology to allow intensivists to remotely and simultaneously care for patients in multiple ICUs. Data evaluating this practice have been limited.

Study design: Pre- and postintervention observational study.

Setting: Open and closed medical-surgical ICUs in community, urban, and tertiary-care teaching U.S. hospitals.

Synopsis: This observational study in six ICUs aimed to assess the association of a telemedicine intervention with clinical outcomes. The intervention consisted of a remote office with real-time audiovisual monitoring, vital signs, early warning signals, and other electronic data. Comparing preintervention (n=2,034) and postintervention (n=2,108) groups, there were no differences in mortality, LOS, or complications.

Overall, the general limitation of the study was that integration of the tele-ICU and actual ICUs was limited. Physicians for nearly two-thirds of the patients chose “minimal delegation” to the tele-ICU physician. Tele-ICU involvement was particularly limited in “closed” units, which were already staffed by on-site intensivists. Furthermore, despite access to various real-time data, critical elements of the record such as physician order entry and progress notes were not shared in real time; notes, for example, required daily faxing.

While it is unfortunate that the study could not evaluate the full potential of the adjunctive tele-ICU, it illustrates the real-world obstacles of integrating such technology into clinical practice. In future studies, a standardized telemedicine approach might facilitate evaluation efforts.

Bottom line: While this study demonstrated no benefit of telemedicine, study limitations preclude conclusions. Further studies are needed.

Citation: Thomas EJ, Lucke JF, Wueste L, Weavind L, Patel B. Association of telemedicine for remote monitoring of intensive care patients with mortality, complications, and length of stay. JAMA. 2009;302(24):2671-2678.

Dr. Kim is a hospitalist at Brigham and Women's Hospital in Boston, and an instructor at Harvard Medical School.

For more reviews of HM-related research, visit our website.

Clinical question: Does remote ICU monitoring improve mortality and length of stay?

Background: A shortage of intensivists has led to increased use of remote ICU monitoring or telemedicine technology to allow intensivists to remotely and simultaneously care for patients in multiple ICUs. Data evaluating this practice have been limited.

Study design: Pre- and postintervention observational study.

Setting: Open and closed medical-surgical ICUs in community, urban, and tertiary-care teaching U.S. hospitals.

Synopsis: This observational study in six ICUs aimed to assess the association of a telemedicine intervention with clinical outcomes. The intervention consisted of a remote office with real-time audiovisual monitoring, vital signs, early warning signals, and other electronic data. Comparing preintervention (n=2,034) and postintervention (n=2,108) groups, there were no differences in mortality, LOS, or complications.

Overall, the general limitation of the study was that integration of the tele-ICU and actual ICUs was limited. Physicians for nearly two-thirds of the patients chose “minimal delegation” to the tele-ICU physician. Tele-ICU involvement was particularly limited in “closed” units, which were already staffed by on-site intensivists. Furthermore, despite access to various real-time data, critical elements of the record such as physician order entry and progress notes were not shared in real time; notes, for example, required daily faxing.

While it is unfortunate that the study could not evaluate the full potential of the adjunctive tele-ICU, it illustrates the real-world obstacles of integrating such technology into clinical practice. In future studies, a standardized telemedicine approach might facilitate evaluation efforts.

Bottom line: While this study demonstrated no benefit of telemedicine, study limitations preclude conclusions. Further studies are needed.

Citation: Thomas EJ, Lucke JF, Wueste L, Weavind L, Patel B. Association of telemedicine for remote monitoring of intensive care patients with mortality, complications, and length of stay. JAMA. 2009;302(24):2671-2678.

Dr. Kim is a hospitalist at Brigham and Women's Hospital in Boston, and an instructor at Harvard Medical School.

For more reviews of HM-related research, visit our website.

Clinical question: Does remote ICU monitoring improve mortality and length of stay?

Background: A shortage of intensivists has led to increased use of remote ICU monitoring or telemedicine technology to allow intensivists to remotely and simultaneously care for patients in multiple ICUs. Data evaluating this practice have been limited.

Study design: Pre- and postintervention observational study.

Setting: Open and closed medical-surgical ICUs in community, urban, and tertiary-care teaching U.S. hospitals.

Synopsis: This observational study in six ICUs aimed to assess the association of a telemedicine intervention with clinical outcomes. The intervention consisted of a remote office with real-time audiovisual monitoring, vital signs, early warning signals, and other electronic data. Comparing preintervention (n=2,034) and postintervention (n=2,108) groups, there were no differences in mortality, LOS, or complications.

Overall, the general limitation of the study was that integration of the tele-ICU and actual ICUs was limited. Physicians for nearly two-thirds of the patients chose “minimal delegation” to the tele-ICU physician. Tele-ICU involvement was particularly limited in “closed” units, which were already staffed by on-site intensivists. Furthermore, despite access to various real-time data, critical elements of the record such as physician order entry and progress notes were not shared in real time; notes, for example, required daily faxing.

While it is unfortunate that the study could not evaluate the full potential of the adjunctive tele-ICU, it illustrates the real-world obstacles of integrating such technology into clinical practice. In future studies, a standardized telemedicine approach might facilitate evaluation efforts.

Bottom line: While this study demonstrated no benefit of telemedicine, study limitations preclude conclusions. Further studies are needed.

Citation: Thomas EJ, Lucke JF, Wueste L, Weavind L, Patel B. Association of telemedicine for remote monitoring of intensive care patients with mortality, complications, and length of stay. JAMA. 2009;302(24):2671-2678.

Dr. Kim is a hospitalist at Brigham and Women's Hospital in Boston, and an instructor at Harvard Medical School.

For more reviews of HM-related research, visit our website.

When and how the national focus on reducing hospital readmissions will hit hospitals’ bottom lines is not clear, but it’s more a matter of when, not if, says Eric Coleman, MD, MPH, AGSF, FACP, director of the Care Transitions Program at the University of Colorado Denver.

Reducing readmissions “jumps off the page as an area where we could see enormous savings in national health expenditures,” Dr. Coleman told participants in an SHM webinar last month. The challenge, he said, is to align incentives with quality and safety for a moving target that also happens to be highly politicized. “We’re generally pretty good at identifying who’s at risk of readmission, but it’s harder to say who’s at modifiable risk,” he explained.

Evidence shows that hospitalists already reduce costs through improved length of stay. “Can hospitalists demonstrate the ability to reduce readmission rates as well?” Dr. Coleman asked.

Bundling payment for hospital stays with various post-hospital providers is a major focus of national efforts to reduce healthcare costs. Bundling gives providers on the healthcare continuum strong motivation to work together, Dr. Coleman said. The government won’t tell providers how to divide bundled payments, but Dr. Coleman predicts that consulting firms offering ideas for divvying up the money will emerge.

The Medicare Payment Advisory Commission (MEDPAC) has signaled its interest in changing payment incentives by reducing reimbursement for readmissions as well as several provisions that directly address readmissions in the healthcare reform package signed by President Obama in March. These include:

- A national pilot program on payment bundling;

- A hospital readmissions reduction program with financial penalties starting in October 2012 for select conditions; and

- A QI program to help hospitals with high severity-adjusted readmission rates.

When and how the national focus on reducing hospital readmissions will hit hospitals’ bottom lines is not clear, but it’s more a matter of when, not if, says Eric Coleman, MD, MPH, AGSF, FACP, director of the Care Transitions Program at the University of Colorado Denver.

Reducing readmissions “jumps off the page as an area where we could see enormous savings in national health expenditures,” Dr. Coleman told participants in an SHM webinar last month. The challenge, he said, is to align incentives with quality and safety for a moving target that also happens to be highly politicized. “We’re generally pretty good at identifying who’s at risk of readmission, but it’s harder to say who’s at modifiable risk,” he explained.

Evidence shows that hospitalists already reduce costs through improved length of stay. “Can hospitalists demonstrate the ability to reduce readmission rates as well?” Dr. Coleman asked.

Bundling payment for hospital stays with various post-hospital providers is a major focus of national efforts to reduce healthcare costs. Bundling gives providers on the healthcare continuum strong motivation to work together, Dr. Coleman said. The government won’t tell providers how to divide bundled payments, but Dr. Coleman predicts that consulting firms offering ideas for divvying up the money will emerge.

The Medicare Payment Advisory Commission (MEDPAC) has signaled its interest in changing payment incentives by reducing reimbursement for readmissions as well as several provisions that directly address readmissions in the healthcare reform package signed by President Obama in March. These include:

- A national pilot program on payment bundling;

- A hospital readmissions reduction program with financial penalties starting in October 2012 for select conditions; and

- A QI program to help hospitals with high severity-adjusted readmission rates.

When and how the national focus on reducing hospital readmissions will hit hospitals’ bottom lines is not clear, but it’s more a matter of when, not if, says Eric Coleman, MD, MPH, AGSF, FACP, director of the Care Transitions Program at the University of Colorado Denver.

Reducing readmissions “jumps off the page as an area where we could see enormous savings in national health expenditures,” Dr. Coleman told participants in an SHM webinar last month. The challenge, he said, is to align incentives with quality and safety for a moving target that also happens to be highly politicized. “We’re generally pretty good at identifying who’s at risk of readmission, but it’s harder to say who’s at modifiable risk,” he explained.

Evidence shows that hospitalists already reduce costs through improved length of stay. “Can hospitalists demonstrate the ability to reduce readmission rates as well?” Dr. Coleman asked.

Bundling payment for hospital stays with various post-hospital providers is a major focus of national efforts to reduce healthcare costs. Bundling gives providers on the healthcare continuum strong motivation to work together, Dr. Coleman said. The government won’t tell providers how to divide bundled payments, but Dr. Coleman predicts that consulting firms offering ideas for divvying up the money will emerge.

The Medicare Payment Advisory Commission (MEDPAC) has signaled its interest in changing payment incentives by reducing reimbursement for readmissions as well as several provisions that directly address readmissions in the healthcare reform package signed by President Obama in March. These include:

- A national pilot program on payment bundling;

- A hospital readmissions reduction program with financial penalties starting in October 2012 for select conditions; and

- A QI program to help hospitals with high severity-adjusted readmission rates.

HM leaders should pay close attention to the landmark decision by President Obama to extend visitation and critical-care decision rights to the partners of gay and lesbian patients, according to one hospitalist.

“The hospitalists would be the gatekeepers, in some ways, to make those calls,” says Heather Whelan, MD, an assistant professor and medical director at Mount Zion Medical Service, Division of Hospital Medicine, at the University of California at San Francisco. “I think hospitalists, group managers, and hospitals themselves are going to build this into policies and practices.”

Via a memo written in mid-April, the president mandated that all hospitals receiving federal funding must extend visitation rights to gay partners and “respect the patient’s choices about who may make critical heath-care decisions for them,” according to the Washington Post. Gay activists cheered the decisions; many conservative groups decried it.

An SHM spokesperson says the society “always expects that its hospitalists and their policies know and comply with federal, state and local regulations.”

Dr. Whelan notes that many hospitals in more progressive areas of the country—including San Francisco and New York City—already extend the rights that Obama has now codified. However, she says she has heard from physicians working elsewhere that the issue can crop up on who can be involved in critical-care meetings and decisions. The issue can be particularly sensitive in cases in which the patient is noncommunicative due to a stroke or other acute condition.

“This will standardize care,” Dr. Whelan says, adding, “It almost doesn’t matter how frequently it comes up. It’s a high-stakes event. One or two instances of it coming up are too many.”

HM leaders should pay close attention to the landmark decision by President Obama to extend visitation and critical-care decision rights to the partners of gay and lesbian patients, according to one hospitalist.

“The hospitalists would be the gatekeepers, in some ways, to make those calls,” says Heather Whelan, MD, an assistant professor and medical director at Mount Zion Medical Service, Division of Hospital Medicine, at the University of California at San Francisco. “I think hospitalists, group managers, and hospitals themselves are going to build this into policies and practices.”

Via a memo written in mid-April, the president mandated that all hospitals receiving federal funding must extend visitation rights to gay partners and “respect the patient’s choices about who may make critical heath-care decisions for them,” according to the Washington Post. Gay activists cheered the decisions; many conservative groups decried it.

An SHM spokesperson says the society “always expects that its hospitalists and their policies know and comply with federal, state and local regulations.”

Dr. Whelan notes that many hospitals in more progressive areas of the country—including San Francisco and New York City—already extend the rights that Obama has now codified. However, she says she has heard from physicians working elsewhere that the issue can crop up on who can be involved in critical-care meetings and decisions. The issue can be particularly sensitive in cases in which the patient is noncommunicative due to a stroke or other acute condition.

“This will standardize care,” Dr. Whelan says, adding, “It almost doesn’t matter how frequently it comes up. It’s a high-stakes event. One or two instances of it coming up are too many.”

HM leaders should pay close attention to the landmark decision by President Obama to extend visitation and critical-care decision rights to the partners of gay and lesbian patients, according to one hospitalist.

“The hospitalists would be the gatekeepers, in some ways, to make those calls,” says Heather Whelan, MD, an assistant professor and medical director at Mount Zion Medical Service, Division of Hospital Medicine, at the University of California at San Francisco. “I think hospitalists, group managers, and hospitals themselves are going to build this into policies and practices.”

Via a memo written in mid-April, the president mandated that all hospitals receiving federal funding must extend visitation rights to gay partners and “respect the patient’s choices about who may make critical heath-care decisions for them,” according to the Washington Post. Gay activists cheered the decisions; many conservative groups decried it.

An SHM spokesperson says the society “always expects that its hospitalists and their policies know and comply with federal, state and local regulations.”

Dr. Whelan notes that many hospitals in more progressive areas of the country—including San Francisco and New York City—already extend the rights that Obama has now codified. However, she says she has heard from physicians working elsewhere that the issue can crop up on who can be involved in critical-care meetings and decisions. The issue can be particularly sensitive in cases in which the patient is noncommunicative due to a stroke or other acute condition.

“This will standardize care,” Dr. Whelan says, adding, “It almost doesn’t matter how frequently it comes up. It’s a high-stakes event. One or two instances of it coming up are too many.”

Jitendra Dassani, MD, is a hospitalist who works for Advocate Medical Group at Illinois Masonic Hospital in Chicago. He passed the American Board of Internal Medicine’s (ABIM) traditional internal-medicine Maintenance of Certification (MOC) examination in 2008. According to current guidelines, he won’t have to recertify until 2018.

But Dr. Dassani is more than a veteran hospitalist. He’s practiced hospital-based medicine for well over a decade, and is planning on a long and prosperous HM career. In fact, he’s so dedicated to the field that he is planning to recertify through ABIM’s new Focused Practice in Hospital Medicine (FPHM) MOC next year—or, at the very latest, in 2012.

“I’ve been a hospitalist for 13 years, and I think it’s important to have something that can assess your knowledge and abilities as a hospitalist,” says Dr. Dassani, one of nearly 200 hospitalists who have signed up for the FPHM pathway. The first secure exam will be administered in October. “I took the general IM exam in 2008. That’s the traditional ABIM boards; I felt some of the questions were not related to my practice. That’s why I think the [FPHM] is really good and really important.”

He’s not alone. SHM and ABIM are anxious to see where this new MOC pathway goes. SHM leaders think the FPHM offers career validation and a customized MOC process to the 30,000 hospitalists practicing nationwide. ABIM is planning an extensive research effort to analyze a focused-practice MOC, using hospitalists as the test subjects.

One area in which the FPHM varies from the traditional MOC is its every-three-year requirement to complete practice-improvement modules (PIMs). Dr. Dassani likens the higher standard to the kind of continuing education and training programs other specialized fields require.

“I think it’s a good idea. It’s more work, but I support it,” he says. “Every time you get onto a plane, you hope the pilot is certified every six months, versus no one has evaluated the pilot in two years. Your safety is in his hands. Take that same analogy to medicine.

“You will have time,” he adds. “It’s 60 points over three years. One PIM is 40 points, so it’s not overwhelming.”—JC

Jitendra Dassani, MD, is a hospitalist who works for Advocate Medical Group at Illinois Masonic Hospital in Chicago. He passed the American Board of Internal Medicine’s (ABIM) traditional internal-medicine Maintenance of Certification (MOC) examination in 2008. According to current guidelines, he won’t have to recertify until 2018.

But Dr. Dassani is more than a veteran hospitalist. He’s practiced hospital-based medicine for well over a decade, and is planning on a long and prosperous HM career. In fact, he’s so dedicated to the field that he is planning to recertify through ABIM’s new Focused Practice in Hospital Medicine (FPHM) MOC next year—or, at the very latest, in 2012.

“I’ve been a hospitalist for 13 years, and I think it’s important to have something that can assess your knowledge and abilities as a hospitalist,” says Dr. Dassani, one of nearly 200 hospitalists who have signed up for the FPHM pathway. The first secure exam will be administered in October. “I took the general IM exam in 2008. That’s the traditional ABIM boards; I felt some of the questions were not related to my practice. That’s why I think the [FPHM] is really good and really important.”

He’s not alone. SHM and ABIM are anxious to see where this new MOC pathway goes. SHM leaders think the FPHM offers career validation and a customized MOC process to the 30,000 hospitalists practicing nationwide. ABIM is planning an extensive research effort to analyze a focused-practice MOC, using hospitalists as the test subjects.

One area in which the FPHM varies from the traditional MOC is its every-three-year requirement to complete practice-improvement modules (PIMs). Dr. Dassani likens the higher standard to the kind of continuing education and training programs other specialized fields require.

“I think it’s a good idea. It’s more work, but I support it,” he says. “Every time you get onto a plane, you hope the pilot is certified every six months, versus no one has evaluated the pilot in two years. Your safety is in his hands. Take that same analogy to medicine.

“You will have time,” he adds. “It’s 60 points over three years. One PIM is 40 points, so it’s not overwhelming.”—JC

Jitendra Dassani, MD, is a hospitalist who works for Advocate Medical Group at Illinois Masonic Hospital in Chicago. He passed the American Board of Internal Medicine’s (ABIM) traditional internal-medicine Maintenance of Certification (MOC) examination in 2008. According to current guidelines, he won’t have to recertify until 2018.

But Dr. Dassani is more than a veteran hospitalist. He’s practiced hospital-based medicine for well over a decade, and is planning on a long and prosperous HM career. In fact, he’s so dedicated to the field that he is planning to recertify through ABIM’s new Focused Practice in Hospital Medicine (FPHM) MOC next year—or, at the very latest, in 2012.

“I’ve been a hospitalist for 13 years, and I think it’s important to have something that can assess your knowledge and abilities as a hospitalist,” says Dr. Dassani, one of nearly 200 hospitalists who have signed up for the FPHM pathway. The first secure exam will be administered in October. “I took the general IM exam in 2008. That’s the traditional ABIM boards; I felt some of the questions were not related to my practice. That’s why I think the [FPHM] is really good and really important.”

He’s not alone. SHM and ABIM are anxious to see where this new MOC pathway goes. SHM leaders think the FPHM offers career validation and a customized MOC process to the 30,000 hospitalists practicing nationwide. ABIM is planning an extensive research effort to analyze a focused-practice MOC, using hospitalists as the test subjects.

One area in which the FPHM varies from the traditional MOC is its every-three-year requirement to complete practice-improvement modules (PIMs). Dr. Dassani likens the higher standard to the kind of continuing education and training programs other specialized fields require.

“I think it’s a good idea. It’s more work, but I support it,” he says. “Every time you get onto a plane, you hope the pilot is certified every six months, versus no one has evaluated the pilot in two years. Your safety is in his hands. Take that same analogy to medicine.

“You will have time,” he adds. “It’s 60 points over three years. One PIM is 40 points, so it’s not overwhelming.”—JC

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