QI Initiatives

An evaluation of the Pennsylvania-based Geisinger Health System’s ProvenHealth Navigator, a patient-centered medical home (PCMH) model, found that hospitalizations have been reduced by 18% for all patients.¹

The National Institutes on Aging-sponsored project Geriatric Resources for Assessment and Care of Elders (GRACE), which also functioned according to several PCMH principles, reduced hospitalizations by 40% and 44% in its second and third years, another evaluation showed.^2,3

And in the Veterans Affairs-managed Home-Based Primary Care project, another PCMH-based effort, readmissions were reduced by 22% in the first six months, but the reduction wasn’t sustained for the rest of the year.⁴

Those findings are among the most definitive so far on the effects of the PCMH on hospitalization rates, according to an Agency for Healthcare Research and Quality (AHRQ) report published in February.

The report concluded that among the statistically significant findings in the biggest PCMH evaluations, favorable results far outnumbered unfavorable results—on outcomes, ED use, and patient experience.

But AHRQ also found that most studies have been inconclusive due to problems with their methodologies. For instance, many studies don’t factor in “clustering,” in which patient outcomes within a practice can be expected to be similar to that of other patients at that practice. AHRQ’s report evaluated the results only from studies it determined had methodologies that were sufficiently rigorous.

The evaluation of the GRACE project was the only evaluation that found any evidence of savings, according to the report. But that study was one of only four on the topic that were deemed worth consideration.

David Meyers, MD, director of the Center for Primary Care, Prevention, and Clinical Partnerships at AHRQ, points out that the systems that have been evaluated are the very earliest adopters of PCMH principles. Researchers estimate that it could take 10 years to get reliable results.

“The good news,” Dr. Meyers says, “is that there are a lot more demonstrations happening now, so we soon will have a lot more guidance about how to make this model work.”

Tom Collins is a freelance writer in South Florida.

References

1. Gilfillan RJ, Tomcavage J, Rosenthal MB, et al. Value and the medical home: Effects of transformed primary care. Am J Manag Care. 2010;16(8):607-614.

2. Bielaszka-DuVernay, et al. The “GRACE” model: in-home assessments lead to better care for dual eligibles. Health Aff (Millwood). 2011;30(3):431-434.

3. Counsell SR, Callahan CM, Tu W, Stump TE, Arling GW. Cost analysis of the Geriatric Resources for Assessment and Care of Elders care management intervention. J Am Geriatr Soc. 2009;57(8):1420-1426.

4. Hughes SL, Weaver FM, Giobbie-Hurder A, et al. Effectiveness of team-managed home-based primary care: a randomized multicenter trial. JAMA. 2000;284(22):2877-2885.

 

An evaluation of the Pennsylvania-based Geisinger Health System’s ProvenHealth Navigator, a patient-centered medical home (PCMH) model, found that hospitalizations have been reduced by 18% for all patients.¹

The National Institutes on Aging-sponsored project Geriatric Resources for Assessment and Care of Elders (GRACE), which also functioned according to several PCMH principles, reduced hospitalizations by 40% and 44% in its second and third years, another evaluation showed.^2,3

And in the Veterans Affairs-managed Home-Based Primary Care project, another PCMH-based effort, readmissions were reduced by 22% in the first six months, but the reduction wasn’t sustained for the rest of the year.⁴

Those findings are among the most definitive so far on the effects of the PCMH on hospitalization rates, according to an Agency for Healthcare Research and Quality (AHRQ) report published in February.

The report concluded that among the statistically significant findings in the biggest PCMH evaluations, favorable results far outnumbered unfavorable results—on outcomes, ED use, and patient experience.

But AHRQ also found that most studies have been inconclusive due to problems with their methodologies. For instance, many studies don’t factor in “clustering,” in which patient outcomes within a practice can be expected to be similar to that of other patients at that practice. AHRQ’s report evaluated the results only from studies it determined had methodologies that were sufficiently rigorous.

The evaluation of the GRACE project was the only evaluation that found any evidence of savings, according to the report. But that study was one of only four on the topic that were deemed worth consideration.

David Meyers, MD, director of the Center for Primary Care, Prevention, and Clinical Partnerships at AHRQ, points out that the systems that have been evaluated are the very earliest adopters of PCMH principles. Researchers estimate that it could take 10 years to get reliable results.

“The good news,” Dr. Meyers says, “is that there are a lot more demonstrations happening now, so we soon will have a lot more guidance about how to make this model work.”

Tom Collins is a freelance writer in South Florida.

References

1. Gilfillan RJ, Tomcavage J, Rosenthal MB, et al. Value and the medical home: Effects of transformed primary care. Am J Manag Care. 2010;16(8):607-614.

2. Bielaszka-DuVernay, et al. The “GRACE” model: in-home assessments lead to better care for dual eligibles. Health Aff (Millwood). 2011;30(3):431-434.

3. Counsell SR, Callahan CM, Tu W, Stump TE, Arling GW. Cost analysis of the Geriatric Resources for Assessment and Care of Elders care management intervention. J Am Geriatr Soc. 2009;57(8):1420-1426.

4. Hughes SL, Weaver FM, Giobbie-Hurder A, et al. Effectiveness of team-managed home-based primary care: a randomized multicenter trial. JAMA. 2000;284(22):2877-2885.

 

An evaluation of the Pennsylvania-based Geisinger Health System’s ProvenHealth Navigator, a patient-centered medical home (PCMH) model, found that hospitalizations have been reduced by 18% for all patients.¹

The National Institutes on Aging-sponsored project Geriatric Resources for Assessment and Care of Elders (GRACE), which also functioned according to several PCMH principles, reduced hospitalizations by 40% and 44% in its second and third years, another evaluation showed.^2,3

And in the Veterans Affairs-managed Home-Based Primary Care project, another PCMH-based effort, readmissions were reduced by 22% in the first six months, but the reduction wasn’t sustained for the rest of the year.⁴

Those findings are among the most definitive so far on the effects of the PCMH on hospitalization rates, according to an Agency for Healthcare Research and Quality (AHRQ) report published in February.

The report concluded that among the statistically significant findings in the biggest PCMH evaluations, favorable results far outnumbered unfavorable results—on outcomes, ED use, and patient experience.

But AHRQ also found that most studies have been inconclusive due to problems with their methodologies. For instance, many studies don’t factor in “clustering,” in which patient outcomes within a practice can be expected to be similar to that of other patients at that practice. AHRQ’s report evaluated the results only from studies it determined had methodologies that were sufficiently rigorous.

The evaluation of the GRACE project was the only evaluation that found any evidence of savings, according to the report. But that study was one of only four on the topic that were deemed worth consideration.

David Meyers, MD, director of the Center for Primary Care, Prevention, and Clinical Partnerships at AHRQ, points out that the systems that have been evaluated are the very earliest adopters of PCMH principles. Researchers estimate that it could take 10 years to get reliable results.

“The good news,” Dr. Meyers says, “is that there are a lot more demonstrations happening now, so we soon will have a lot more guidance about how to make this model work.”

Tom Collins is a freelance writer in South Florida.

References

1. Gilfillan RJ, Tomcavage J, Rosenthal MB, et al. Value and the medical home: Effects of transformed primary care. Am J Manag Care. 2010;16(8):607-614.

2. Bielaszka-DuVernay, et al. The “GRACE” model: in-home assessments lead to better care for dual eligibles. Health Aff (Millwood). 2011;30(3):431-434.

3. Counsell SR, Callahan CM, Tu W, Stump TE, Arling GW. Cost analysis of the Geriatric Resources for Assessment and Care of Elders care management intervention. J Am Geriatr Soc. 2009;57(8):1420-1426.

4. Hughes SL, Weaver FM, Giobbie-Hurder A, et al. Effectiveness of team-managed home-based primary care: a randomized multicenter trial. JAMA. 2000;284(22):2877-2885.

 

Click here to listen to Dr. Eichhorn

Click here to listen to Dr. Eichhorn

Click here to listen to Dr. Eichhorn

Click here to listen to

Dr. Maynard and others at the public hearing

Click here to listen to

Dr. Maynard and others at the public hearing

Click here to listen to

Dr. Maynard and others at the public hearing

In less than four months CMS' Hospital Readmissions Reduction Program will start penalizing hospitals with higher-than-projected readmissions rates. But as the Oct. 1 program launch looms for many hospitals, one readmission initiative is making significant progress to reduce unnecessary hospitalizations.

The Minnesota Reducing Avoidable Readmissions Effectively (RARE) campaign set a goal of preventing 4,000 avoidable readmissions among commercial health plan patients by the end of 2012, a 20% reduction from 2009 baseline data. The campaign was launched last September by three operating partners: the Minnesota Hospital Association (MHA); the Institute for Clinical Systems Improvement (ICSI), a nonprofit collaborative of 55 medical groups and hospitals; and Stratis Health, the state's QI organization. RARE's partners include more than 80 hospitals, which according to the MHA already have prevented 1,011 avoidable readmissions in 2011 and expect to surpass the target goal by the end of 2012.

"We had a specific process for each partner to follow, including a commitment by leadership to support and provide needed resources and development of a guidance team and a working team at each site," says Kathy Cummings, RN, MA, project manager at ICSI.

Each participating hospital was invited to join one of three quality collaboratives: one based on Project RED; one based on Dr. Eric Coleman's Care Transitions model; and one focused on safe transitions-of-care communication developed by the MHA.

"Everyone is rallying around the goals. They are all talking at the table, and starting to break down the silos between hospital, nursing home, clinic, and the chasms in between," says hospitalist Howard Epstein, MD, FHM, ICSI's chief health systems officer. "One of the key attributes of hospitalists is collaboration and systems improvement within their hospitals. Working with RARE is broadening their perspectives on the workings of the healthcare system as a whole."

In less than four months CMS' Hospital Readmissions Reduction Program will start penalizing hospitals with higher-than-projected readmissions rates. But as the Oct. 1 program launch looms for many hospitals, one readmission initiative is making significant progress to reduce unnecessary hospitalizations.

The Minnesota Reducing Avoidable Readmissions Effectively (RARE) campaign set a goal of preventing 4,000 avoidable readmissions among commercial health plan patients by the end of 2012, a 20% reduction from 2009 baseline data. The campaign was launched last September by three operating partners: the Minnesota Hospital Association (MHA); the Institute for Clinical Systems Improvement (ICSI), a nonprofit collaborative of 55 medical groups and hospitals; and Stratis Health, the state's QI organization. RARE's partners include more than 80 hospitals, which according to the MHA already have prevented 1,011 avoidable readmissions in 2011 and expect to surpass the target goal by the end of 2012.

"We had a specific process for each partner to follow, including a commitment by leadership to support and provide needed resources and development of a guidance team and a working team at each site," says Kathy Cummings, RN, MA, project manager at ICSI.

Each participating hospital was invited to join one of three quality collaboratives: one based on Project RED; one based on Dr. Eric Coleman's Care Transitions model; and one focused on safe transitions-of-care communication developed by the MHA.

"Everyone is rallying around the goals. They are all talking at the table, and starting to break down the silos between hospital, nursing home, clinic, and the chasms in between," says hospitalist Howard Epstein, MD, FHM, ICSI's chief health systems officer. "One of the key attributes of hospitalists is collaboration and systems improvement within their hospitals. Working with RARE is broadening their perspectives on the workings of the healthcare system as a whole."

In less than four months CMS' Hospital Readmissions Reduction Program will start penalizing hospitals with higher-than-projected readmissions rates. But as the Oct. 1 program launch looms for many hospitals, one readmission initiative is making significant progress to reduce unnecessary hospitalizations.

The Minnesota Reducing Avoidable Readmissions Effectively (RARE) campaign set a goal of preventing 4,000 avoidable readmissions among commercial health plan patients by the end of 2012, a 20% reduction from 2009 baseline data. The campaign was launched last September by three operating partners: the Minnesota Hospital Association (MHA); the Institute for Clinical Systems Improvement (ICSI), a nonprofit collaborative of 55 medical groups and hospitals; and Stratis Health, the state's QI organization. RARE's partners include more than 80 hospitals, which according to the MHA already have prevented 1,011 avoidable readmissions in 2011 and expect to surpass the target goal by the end of 2012.

"We had a specific process for each partner to follow, including a commitment by leadership to support and provide needed resources and development of a guidance team and a working team at each site," says Kathy Cummings, RN, MA, project manager at ICSI.

Each participating hospital was invited to join one of three quality collaboratives: one based on Project RED; one based on Dr. Eric Coleman's Care Transitions model; and one focused on safe transitions-of-care communication developed by the MHA.

"Everyone is rallying around the goals. They are all talking at the table, and starting to break down the silos between hospital, nursing home, clinic, and the chasms in between," says hospitalist Howard Epstein, MD, FHM, ICSI's chief health systems officer. "One of the key attributes of hospitalists is collaboration and systems improvement within their hospitals. Working with RARE is broadening their perspectives on the workings of the healthcare system as a whole."

Several years ago, Presbyterian Medical Group in Albuquerque, N.M., decided to integrate three elements of its healthcare system: its health plan, the employed medical group, and the hospital delivery system. Knitting those parts into a cohesive whole helped the group realize that “lowering the cost of care by improving efficiency, by improving coordination, and by enhancing collaboration between payor and physicians made a lot of sense,” executive medical director David Arredondo, MD, says.

When the accountable care organization (ACO) concept came along, Dr. Arredondo says, “it really was just a natural extension of what we were doing.”

The ACO model, championed as a way to prevent the fragmentation of care and rein in costs by getting providers to assume joint responsibility for specific patient populations, received a major boost through 2010’s Affordable Care Act. Last year’s ACO rule-making process by the Centers for Medicare & Medicaid Services (CMS), however, was anything but smooth. Cautious optimism by such organizations as SHM gave way to loud complaints over the initial rules for a voluntary initiative called the Shared Savings Program. Critics asserted that participants would be forced to assume too much financial risk while being swamped with paperwork requirements.

By year’s end, though, the final rules had assuaged many of the biggest concerns, and the April 10 announcement of 27 participants for the program’s first round—more than half of which are physician-led organizations—has rekindled much of the enthusiasm. According to CMS officials, the agency is reviewing more than 150 applications for the program’s next round, which will begin in July.

Keys to Success

In December, CMS selected 32 organizations to participate in an even more ambitious initiative called the Pioneer ACO Model. That separate but related experiment in shared accountability launched Jan. 1, and it may be months before enrolled organizations can say whether the rewards outweigh the risks. Interviews with Presbyterian’s Dr. Arredondo and two other Pioneer participants about why they took the plunge, however, have highlighted some potential keys to success.

All three agree that the ACO model offers a better match for their long-term, patient-centered goals and that the fee-for-service model is gradually becoming a thing of the past.

“In some ways, it was actually kind of a relief that the system was going this way because we, probably like many systems, were beginning to be caught between the budgeted model and a fee-for-service model,” Dr. Arredondo says. “When you’re heavily one way or heavily the other way, then it makes things a little easier to manage and understand. When you’re right in the middle, it becomes a little uncomfortable.”

Penny Wheeler, MD, chief clinical officer for Minneapolis-based Allina Hospitals & Clinics, says organizations in that precarious position need to carefully examine their capabilities and consider how best to pace their transition. Otherwise, they might prematurely give up too much revenue that could be used to reinvest in care improvements.

“We can tolerate it if we shoot ourselves in one foot, but we can’t tolerate it if we shoot ourselves in both feet, in this new world,” Dr. Wheeler says.

If caution is warranted, she says, the ACO model still aligns well with a strategy of building toward outcome-based healthcare. Despite the likelihood of “lumps and bumps and warts along the way,” Dr. Wheeler says, “we really wanted to be part of the shaping of that outcome-based delivery, and receive market rewards for what we were creating for our community.”

 

Austin, Texas-based Seton Health Alliance, a third Pioneer participant, is a collaborative effort between a hospital delivery system known as Seton Health Care Family and a multispecialty physician group called Austin Regional Clinic. Greg Sheff, MD, president and chief medical officer of the ACO, says the partnering organizations were separately moving toward more population health initiatives and more proactive, coordinated, and accountable care.

“The Pioneer ACO, for us, really provided an opportunity to light the fire and motivate the organizations to put the entity together and start doing the work,” he says, adding PCPs and hospitalists will be critical to his organization’s ongoing integration efforts.

“The areas where there are opportunities to be more efficient are largely under the care of the hospitalists,” he says, citing in-house utilization as well as care transitions, comprehensive post-acute placement, and readmission prevention efforts. To support those providers, Pioneer participants say well-designed electronic medical records are paramount, while separate efforts, such as patient-centered medical homes and unit-based rounding, might offer timely assists. (Click here to listen to more of The Hospitalist’s interview with Dr. Sheff.)

No one’s expecting the next few years to be seamless, but Dr. Sheff views his newly formed ACO as a long-term endeavor in which success isn’t necessarily defined by whether the group achieves shared cost savings.

“We define success by whether we are able to move our delivery system to a place where we’ll be much more adept at going forward, continuing to manage populations,” he says. “We really see this as a strategic organizational decision more than, ‘Boy, that contract looks like something that we can leverage in the short term.’”

Bryn Nelson is a freelance medical writer in Seattle.

 

Several years ago, Presbyterian Medical Group in Albuquerque, N.M., decided to integrate three elements of its healthcare system: its health plan, the employed medical group, and the hospital delivery system. Knitting those parts into a cohesive whole helped the group realize that “lowering the cost of care by improving efficiency, by improving coordination, and by enhancing collaboration between payor and physicians made a lot of sense,” executive medical director David Arredondo, MD, says.

When the accountable care organization (ACO) concept came along, Dr. Arredondo says, “it really was just a natural extension of what we were doing.”

The ACO model, championed as a way to prevent the fragmentation of care and rein in costs by getting providers to assume joint responsibility for specific patient populations, received a major boost through 2010’s Affordable Care Act. Last year’s ACO rule-making process by the Centers for Medicare & Medicaid Services (CMS), however, was anything but smooth. Cautious optimism by such organizations as SHM gave way to loud complaints over the initial rules for a voluntary initiative called the Shared Savings Program. Critics asserted that participants would be forced to assume too much financial risk while being swamped with paperwork requirements.

By year’s end, though, the final rules had assuaged many of the biggest concerns, and the April 10 announcement of 27 participants for the program’s first round—more than half of which are physician-led organizations—has rekindled much of the enthusiasm. According to CMS officials, the agency is reviewing more than 150 applications for the program’s next round, which will begin in July.

Keys to Success

In December, CMS selected 32 organizations to participate in an even more ambitious initiative called the Pioneer ACO Model. That separate but related experiment in shared accountability launched Jan. 1, and it may be months before enrolled organizations can say whether the rewards outweigh the risks. Interviews with Presbyterian’s Dr. Arredondo and two other Pioneer participants about why they took the plunge, however, have highlighted some potential keys to success.

All three agree that the ACO model offers a better match for their long-term, patient-centered goals and that the fee-for-service model is gradually becoming a thing of the past.

“In some ways, it was actually kind of a relief that the system was going this way because we, probably like many systems, were beginning to be caught between the budgeted model and a fee-for-service model,” Dr. Arredondo says. “When you’re heavily one way or heavily the other way, then it makes things a little easier to manage and understand. When you’re right in the middle, it becomes a little uncomfortable.”

Penny Wheeler, MD, chief clinical officer for Minneapolis-based Allina Hospitals & Clinics, says organizations in that precarious position need to carefully examine their capabilities and consider how best to pace their transition. Otherwise, they might prematurely give up too much revenue that could be used to reinvest in care improvements.

“We can tolerate it if we shoot ourselves in one foot, but we can’t tolerate it if we shoot ourselves in both feet, in this new world,” Dr. Wheeler says.

If caution is warranted, she says, the ACO model still aligns well with a strategy of building toward outcome-based healthcare. Despite the likelihood of “lumps and bumps and warts along the way,” Dr. Wheeler says, “we really wanted to be part of the shaping of that outcome-based delivery, and receive market rewards for what we were creating for our community.”

 

Austin, Texas-based Seton Health Alliance, a third Pioneer participant, is a collaborative effort between a hospital delivery system known as Seton Health Care Family and a multispecialty physician group called Austin Regional Clinic. Greg Sheff, MD, president and chief medical officer of the ACO, says the partnering organizations were separately moving toward more population health initiatives and more proactive, coordinated, and accountable care.

“The Pioneer ACO, for us, really provided an opportunity to light the fire and motivate the organizations to put the entity together and start doing the work,” he says, adding PCPs and hospitalists will be critical to his organization’s ongoing integration efforts.

“The areas where there are opportunities to be more efficient are largely under the care of the hospitalists,” he says, citing in-house utilization as well as care transitions, comprehensive post-acute placement, and readmission prevention efforts. To support those providers, Pioneer participants say well-designed electronic medical records are paramount, while separate efforts, such as patient-centered medical homes and unit-based rounding, might offer timely assists. (Click here to listen to more of The Hospitalist’s interview with Dr. Sheff.)

No one’s expecting the next few years to be seamless, but Dr. Sheff views his newly formed ACO as a long-term endeavor in which success isn’t necessarily defined by whether the group achieves shared cost savings.

“We define success by whether we are able to move our delivery system to a place where we’ll be much more adept at going forward, continuing to manage populations,” he says. “We really see this as a strategic organizational decision more than, ‘Boy, that contract looks like something that we can leverage in the short term.’”

Bryn Nelson is a freelance medical writer in Seattle.

 

Several years ago, Presbyterian Medical Group in Albuquerque, N.M., decided to integrate three elements of its healthcare system: its health plan, the employed medical group, and the hospital delivery system. Knitting those parts into a cohesive whole helped the group realize that “lowering the cost of care by improving efficiency, by improving coordination, and by enhancing collaboration between payor and physicians made a lot of sense,” executive medical director David Arredondo, MD, says.

When the accountable care organization (ACO) concept came along, Dr. Arredondo says, “it really was just a natural extension of what we were doing.”

The ACO model, championed as a way to prevent the fragmentation of care and rein in costs by getting providers to assume joint responsibility for specific patient populations, received a major boost through 2010’s Affordable Care Act. Last year’s ACO rule-making process by the Centers for Medicare & Medicaid Services (CMS), however, was anything but smooth. Cautious optimism by such organizations as SHM gave way to loud complaints over the initial rules for a voluntary initiative called the Shared Savings Program. Critics asserted that participants would be forced to assume too much financial risk while being swamped with paperwork requirements.

By year’s end, though, the final rules had assuaged many of the biggest concerns, and the April 10 announcement of 27 participants for the program’s first round—more than half of which are physician-led organizations—has rekindled much of the enthusiasm. According to CMS officials, the agency is reviewing more than 150 applications for the program’s next round, which will begin in July.

Keys to Success

In December, CMS selected 32 organizations to participate in an even more ambitious initiative called the Pioneer ACO Model. That separate but related experiment in shared accountability launched Jan. 1, and it may be months before enrolled organizations can say whether the rewards outweigh the risks. Interviews with Presbyterian’s Dr. Arredondo and two other Pioneer participants about why they took the plunge, however, have highlighted some potential keys to success.

All three agree that the ACO model offers a better match for their long-term, patient-centered goals and that the fee-for-service model is gradually becoming a thing of the past.

“In some ways, it was actually kind of a relief that the system was going this way because we, probably like many systems, were beginning to be caught between the budgeted model and a fee-for-service model,” Dr. Arredondo says. “When you’re heavily one way or heavily the other way, then it makes things a little easier to manage and understand. When you’re right in the middle, it becomes a little uncomfortable.”

Penny Wheeler, MD, chief clinical officer for Minneapolis-based Allina Hospitals & Clinics, says organizations in that precarious position need to carefully examine their capabilities and consider how best to pace their transition. Otherwise, they might prematurely give up too much revenue that could be used to reinvest in care improvements.

“We can tolerate it if we shoot ourselves in one foot, but we can’t tolerate it if we shoot ourselves in both feet, in this new world,” Dr. Wheeler says.

If caution is warranted, she says, the ACO model still aligns well with a strategy of building toward outcome-based healthcare. Despite the likelihood of “lumps and bumps and warts along the way,” Dr. Wheeler says, “we really wanted to be part of the shaping of that outcome-based delivery, and receive market rewards for what we were creating for our community.”

 

Austin, Texas-based Seton Health Alliance, a third Pioneer participant, is a collaborative effort between a hospital delivery system known as Seton Health Care Family and a multispecialty physician group called Austin Regional Clinic. Greg Sheff, MD, president and chief medical officer of the ACO, says the partnering organizations were separately moving toward more population health initiatives and more proactive, coordinated, and accountable care.

“The Pioneer ACO, for us, really provided an opportunity to light the fire and motivate the organizations to put the entity together and start doing the work,” he says, adding PCPs and hospitalists will be critical to his organization’s ongoing integration efforts.

“The areas where there are opportunities to be more efficient are largely under the care of the hospitalists,” he says, citing in-house utilization as well as care transitions, comprehensive post-acute placement, and readmission prevention efforts. To support those providers, Pioneer participants say well-designed electronic medical records are paramount, while separate efforts, such as patient-centered medical homes and unit-based rounding, might offer timely assists. (Click here to listen to more of The Hospitalist’s interview with Dr. Sheff.)

No one’s expecting the next few years to be seamless, but Dr. Sheff views his newly formed ACO as a long-term endeavor in which success isn’t necessarily defined by whether the group achieves shared cost savings.

“We define success by whether we are able to move our delivery system to a place where we’ll be much more adept at going forward, continuing to manage populations,” he says. “We really see this as a strategic organizational decision more than, ‘Boy, that contract looks like something that we can leverage in the short term.’”

Bryn Nelson is a freelance medical writer in Seattle.

 

A new report on acute myocardial infarction (AMI) suggests that implementing a handful of relatively easy strategies can improve mortality rates.

The research, "Hospital Strategies for Reducing Risk-Standardized Mortality Rates in Acute Myocardial Infarction," highlights several techniques for lowering risk-standardized mortality rates (RSMR) in this patient population:

• Holding monthly meetings to review AMI cases (lowered RSMR by 0.7%);

• Fostering an environment that encourages clinicians to solve problems creatively (lowered RSMR by 0.84%);

• Having 24-hour coverage by cardiologists (lowered RSMR by 0.54%);

• Having both a nurse and physician champion for quality in AMI (lowered RSMR by 0.88%); and

• Avoiding cross-training nurses from ICUs for cardiac catheterization laboratories (lowered RSMR by 0.44%).

Fewer than 10% of the 537 hospitals in the cross-sectional survey reported using at least four of the five strategies. Lead author Elizabeth H. Bradley, PhD, faculty director of the Global Health Leadership Institute and professor of public health at Yale University, says the challenge in implementing the strategies lies in changing the often-obstinate culture of healthcare institutions.

"The root of this is the culture," she says, adding if nothing else, "begin with the problems, begin with an analytical mind when errors occur." Dr. Bradley adds that culture of teamwork works only when it has buy-in from in-the-trenches physicians, such as hospitalists and C-suite executives.

"It has to come from the front line and from the top," she says. "In all of our studies over the last decade, [physicians and administrators] need to be supportive of an environment in which problem solving can happen."

A new report on acute myocardial infarction (AMI) suggests that implementing a handful of relatively easy strategies can improve mortality rates.

The research, "Hospital Strategies for Reducing Risk-Standardized Mortality Rates in Acute Myocardial Infarction," highlights several techniques for lowering risk-standardized mortality rates (RSMR) in this patient population:

• Holding monthly meetings to review AMI cases (lowered RSMR by 0.7%);

• Fostering an environment that encourages clinicians to solve problems creatively (lowered RSMR by 0.84%);

• Having 24-hour coverage by cardiologists (lowered RSMR by 0.54%);

• Having both a nurse and physician champion for quality in AMI (lowered RSMR by 0.88%); and

• Avoiding cross-training nurses from ICUs for cardiac catheterization laboratories (lowered RSMR by 0.44%).

Fewer than 10% of the 537 hospitals in the cross-sectional survey reported using at least four of the five strategies. Lead author Elizabeth H. Bradley, PhD, faculty director of the Global Health Leadership Institute and professor of public health at Yale University, says the challenge in implementing the strategies lies in changing the often-obstinate culture of healthcare institutions.

"The root of this is the culture," she says, adding if nothing else, "begin with the problems, begin with an analytical mind when errors occur." Dr. Bradley adds that culture of teamwork works only when it has buy-in from in-the-trenches physicians, such as hospitalists and C-suite executives.

"It has to come from the front line and from the top," she says. "In all of our studies over the last decade, [physicians and administrators] need to be supportive of an environment in which problem solving can happen."

A new report on acute myocardial infarction (AMI) suggests that implementing a handful of relatively easy strategies can improve mortality rates.

The research, "Hospital Strategies for Reducing Risk-Standardized Mortality Rates in Acute Myocardial Infarction," highlights several techniques for lowering risk-standardized mortality rates (RSMR) in this patient population:

• Holding monthly meetings to review AMI cases (lowered RSMR by 0.7%);

• Fostering an environment that encourages clinicians to solve problems creatively (lowered RSMR by 0.84%);

• Having 24-hour coverage by cardiologists (lowered RSMR by 0.54%);

• Having both a nurse and physician champion for quality in AMI (lowered RSMR by 0.88%); and

• Avoiding cross-training nurses from ICUs for cardiac catheterization laboratories (lowered RSMR by 0.44%).

Fewer than 10% of the 537 hospitals in the cross-sectional survey reported using at least four of the five strategies. Lead author Elizabeth H. Bradley, PhD, faculty director of the Global Health Leadership Institute and professor of public health at Yale University, says the challenge in implementing the strategies lies in changing the often-obstinate culture of healthcare institutions.

"The root of this is the culture," she says, adding if nothing else, "begin with the problems, begin with an analytical mind when errors occur." Dr. Bradley adds that culture of teamwork works only when it has buy-in from in-the-trenches physicians, such as hospitalists and C-suite executives.

"It has to come from the front line and from the top," she says. "In all of our studies over the last decade, [physicians and administrators] need to be supportive of an environment in which problem solving can happen."

Click here to listen to Dr. Barrett

Click here to listen to Dr. Barrett

Click here to listen to Dr. Barrett

Banner Good Samaritan Medical Center in Phoenix is combating hospital-acquired VTE with a quality initiative that uses risk-assessment tools and order sets embedded in the electronic health record (EHR) and real-time interventions with physicians.

Cases of hospital-acquired VTE are identified as they occur and assessed for whether they were preventable, says Lori Porter, DO, academic hospitalist and team leader for Banner Good Samaritan's VTE Committee. "If we think the VTE was preventable, we will call the provider and say, 'Can you tell me why you think this happened?'" she says. (Check out more information about Banner Good Samaritan’s VTE program at the Institute for Healthcare Improvement website.)

The program emphasizes risk re-assessment, appropriate use of extended prophylaxis, and involvement of Banner's house staff. All four hospitalist services at Banner Good Samaritan have been receptive to using the order sets.

Banner Good Samaritan's results include a drop in preventable hospital-acquired VTEs to 25% in 2011 from 45% in 2009, along with a 29% relative risk reduction in DVT and 18% in pulmonary embolism.

The hospital belongs to SHM's VTE Prevention Collaborative, and works with mentor Gregory Maynard, MD, MSc, SFHM, senior vice president of SHM's Center for Healthcare Improvement and Innovation. It uses what Dr. Porter calls "a simple, three-bucket system" for assessing and classifying risk level, derived from the 2008 antithrombotic therapy guidelines from the American College of Chest Physicians (ACCP). However, in February, ACCP issued a new edition of the guidelines, which Dr. Porter has not been eager to embrace.

"They've gone back to a conservative point-scoring system for risk assessment, which seems cumbersome in clinical practice. If a simpler approach has proven to be effective for us, then why commit to making a complicated change?" says Dr. Porter.

Dr. Maynard agrees that the new antithrombotic guidelines have sparked differences of opinion. Dr. Porter's teams, for example, "use the simpler three-bucket model with good results: better prophylaxis, decrease in VTE, and no discernible increase in bleeding," he says. "Improvement teams that want to mimic these results should look at this model, in addition to the models outlined in the ninth edition, and see which models their doctors and nurses would actually use reliably."

 

Banner Good Samaritan Medical Center in Phoenix is combating hospital-acquired VTE with a quality initiative that uses risk-assessment tools and order sets embedded in the electronic health record (EHR) and real-time interventions with physicians.

Cases of hospital-acquired VTE are identified as they occur and assessed for whether they were preventable, says Lori Porter, DO, academic hospitalist and team leader for Banner Good Samaritan's VTE Committee. "If we think the VTE was preventable, we will call the provider and say, 'Can you tell me why you think this happened?'" she says. (Check out more information about Banner Good Samaritan’s VTE program at the Institute for Healthcare Improvement website.)

The program emphasizes risk re-assessment, appropriate use of extended prophylaxis, and involvement of Banner's house staff. All four hospitalist services at Banner Good Samaritan have been receptive to using the order sets.

Banner Good Samaritan's results include a drop in preventable hospital-acquired VTEs to 25% in 2011 from 45% in 2009, along with a 29% relative risk reduction in DVT and 18% in pulmonary embolism.

The hospital belongs to SHM's VTE Prevention Collaborative, and works with mentor Gregory Maynard, MD, MSc, SFHM, senior vice president of SHM's Center for Healthcare Improvement and Innovation. It uses what Dr. Porter calls "a simple, three-bucket system" for assessing and classifying risk level, derived from the 2008 antithrombotic therapy guidelines from the American College of Chest Physicians (ACCP). However, in February, ACCP issued a new edition of the guidelines, which Dr. Porter has not been eager to embrace.

"They've gone back to a conservative point-scoring system for risk assessment, which seems cumbersome in clinical practice. If a simpler approach has proven to be effective for us, then why commit to making a complicated change?" says Dr. Porter.

Dr. Maynard agrees that the new antithrombotic guidelines have sparked differences of opinion. Dr. Porter's teams, for example, "use the simpler three-bucket model with good results: better prophylaxis, decrease in VTE, and no discernible increase in bleeding," he says. "Improvement teams that want to mimic these results should look at this model, in addition to the models outlined in the ninth edition, and see which models their doctors and nurses would actually use reliably."

 

Banner Good Samaritan Medical Center in Phoenix is combating hospital-acquired VTE with a quality initiative that uses risk-assessment tools and order sets embedded in the electronic health record (EHR) and real-time interventions with physicians.

Cases of hospital-acquired VTE are identified as they occur and assessed for whether they were preventable, says Lori Porter, DO, academic hospitalist and team leader for Banner Good Samaritan's VTE Committee. "If we think the VTE was preventable, we will call the provider and say, 'Can you tell me why you think this happened?'" she says. (Check out more information about Banner Good Samaritan’s VTE program at the Institute for Healthcare Improvement website.)

The program emphasizes risk re-assessment, appropriate use of extended prophylaxis, and involvement of Banner's house staff. All four hospitalist services at Banner Good Samaritan have been receptive to using the order sets.

Banner Good Samaritan's results include a drop in preventable hospital-acquired VTEs to 25% in 2011 from 45% in 2009, along with a 29% relative risk reduction in DVT and 18% in pulmonary embolism.

The hospital belongs to SHM's VTE Prevention Collaborative, and works with mentor Gregory Maynard, MD, MSc, SFHM, senior vice president of SHM's Center for Healthcare Improvement and Innovation. It uses what Dr. Porter calls "a simple, three-bucket system" for assessing and classifying risk level, derived from the 2008 antithrombotic therapy guidelines from the American College of Chest Physicians (ACCP). However, in February, ACCP issued a new edition of the guidelines, which Dr. Porter has not been eager to embrace.

"They've gone back to a conservative point-scoring system for risk assessment, which seems cumbersome in clinical practice. If a simpler approach has proven to be effective for us, then why commit to making a complicated change?" says Dr. Porter.

Dr. Maynard agrees that the new antithrombotic guidelines have sparked differences of opinion. Dr. Porter's teams, for example, "use the simpler three-bucket model with good results: better prophylaxis, decrease in VTE, and no discernible increase in bleeding," he says. "Improvement teams that want to mimic these results should look at this model, in addition to the models outlined in the ninth edition, and see which models their doctors and nurses would actually use reliably."

 

Hospitals that have made it to the advanced stages of electronic health record (EHR) implementation are significantly more likely to set national benchmarks for quality and safety performance, according to the 2012 HIMSS Analytics Report.

The research (PDF), sponsored by Thomson Reuters and HIMSS Analytics, found a correlation between hospitals that are both ranked in the Thomson Reuters 100 Top Hospitals and at the upper end of the seven-stage HIMMS scale for EHR adoption.

While the link between electronic implementation and quality is important, William Bria, MD, chief medical information officer at Shriners Hospitals for Children in Philadelphia, cautions hospitalists and others from taking too much comfort in it. Simply implementing EHR and other technologies doesn't work, he says; the system has to be crafted in conjunction with its users.

"The best-led organizations in the country are using the metrics of safety and quality of care right alongside the implementation plan of their [health IT] programs," says Dr. Bria. "And the only way this occurs, of course, is if the partnering between executive and technological leadership and clinical leadership occurs."

Dr. Bria views research on the success of EHRs in improving hospital performance as an opportunity for hospitalists to get more involved in both the planning and implementation processes. He urges hospitalists to work with other physicians and IT staffers to learn how best to use their EHR, and not assume they can master complex software systems as easily as they understand smartphones and tablet computers.

"You can buy a piano and bang on it with your fist, and you won't really attract anybody to listen to your music," Dr. Bria says. "On the other hand, if you learn how to play, you study hard, and you learn the nuances of musicianship, you can become a Van Cliburn."

Hospitals that have made it to the advanced stages of electronic health record (EHR) implementation are significantly more likely to set national benchmarks for quality and safety performance, according to the 2012 HIMSS Analytics Report.

The research (PDF), sponsored by Thomson Reuters and HIMSS Analytics, found a correlation between hospitals that are both ranked in the Thomson Reuters 100 Top Hospitals and at the upper end of the seven-stage HIMMS scale for EHR adoption.

While the link between electronic implementation and quality is important, William Bria, MD, chief medical information officer at Shriners Hospitals for Children in Philadelphia, cautions hospitalists and others from taking too much comfort in it. Simply implementing EHR and other technologies doesn't work, he says; the system has to be crafted in conjunction with its users.

"The best-led organizations in the country are using the metrics of safety and quality of care right alongside the implementation plan of their [health IT] programs," says Dr. Bria. "And the only way this occurs, of course, is if the partnering between executive and technological leadership and clinical leadership occurs."

Dr. Bria views research on the success of EHRs in improving hospital performance as an opportunity for hospitalists to get more involved in both the planning and implementation processes. He urges hospitalists to work with other physicians and IT staffers to learn how best to use their EHR, and not assume they can master complex software systems as easily as they understand smartphones and tablet computers.

"You can buy a piano and bang on it with your fist, and you won't really attract anybody to listen to your music," Dr. Bria says. "On the other hand, if you learn how to play, you study hard, and you learn the nuances of musicianship, you can become a Van Cliburn."

Hospitals that have made it to the advanced stages of electronic health record (EHR) implementation are significantly more likely to set national benchmarks for quality and safety performance, according to the 2012 HIMSS Analytics Report.

The research (PDF), sponsored by Thomson Reuters and HIMSS Analytics, found a correlation between hospitals that are both ranked in the Thomson Reuters 100 Top Hospitals and at the upper end of the seven-stage HIMMS scale for EHR adoption.

While the link between electronic implementation and quality is important, William Bria, MD, chief medical information officer at Shriners Hospitals for Children in Philadelphia, cautions hospitalists and others from taking too much comfort in it. Simply implementing EHR and other technologies doesn't work, he says; the system has to be crafted in conjunction with its users.

"The best-led organizations in the country are using the metrics of safety and quality of care right alongside the implementation plan of their [health IT] programs," says Dr. Bria. "And the only way this occurs, of course, is if the partnering between executive and technological leadership and clinical leadership occurs."

Dr. Bria views research on the success of EHRs in improving hospital performance as an opportunity for hospitalists to get more involved in both the planning and implementation processes. He urges hospitalists to work with other physicians and IT staffers to learn how best to use their EHR, and not assume they can master complex software systems as easily as they understand smartphones and tablet computers.

"You can buy a piano and bang on it with your fist, and you won't really attract anybody to listen to your music," Dr. Bria says. "On the other hand, if you learn how to play, you study hard, and you learn the nuances of musicianship, you can become a Van Cliburn."

Stroke specialists like to say that “time is brain.” With an emphatic focus on those first few critical hours, however, it’s sometimes easy to overlook the vital role that hospitalists play in the days, weeks, and months that follow.

A recent study in The Neurohospitalist suggests that compared to community-based neurologists, practitioners of neurohospital medicine can reduce the length of stay for patients with ischemic stroke.¹ A separate study, however, suggests that similar success might have come at a price for their less-specialized hospitalist counterparts.² Among stroke patients, the latter study found that while the HM model is also associated with a reduced length of stay, it is associated with increased discharges to inpatient rehabilitation centers instead of to home, and higher readmission rates.

In sum, the evidence raises questions about whether rank-and-file hospitalists are adequately equipped to deal with a disease that is a core competency for the profession and ranks among the top sources of adult disability in the United States, at an estimated cost of $34.3 billion in 2008.³

“I think there’s been a mismatch between the training of the average hospitalist and then the expectations for the amount of neurological care they end up delivering once in practice,” says David Likosky, MD, SFHM, director of the stroke program at Evergreen Hospital Medical Center in Kirkland, Wash. “When surveyed, it’s been shown that hospitalists feel that care of stroke is one of the areas with which they’re least comfortable once they get out into practice.” Over the past decade, several studies have reinforced the notion of a training deficit.^4,5

Demographic trends suggest that getting up to speed will be imperative, however. “One alarming thing we’re seeing is strokes among individuals that are not in the elderly group, and that group seems to be increasing at an alarming rate,” says Daniel T. Lackland, PhD, professor of epidemiology and neurosciences at the Medical University of South Carolina in Charleston. Hospitals are seeing more ischemic stroke patients in their 40s and 50s, likely a reflection of risk factors such as hypertension, diabetes, and hyperlipidemia that are occurring earlier in life. And because those patients are younger, the aftermath of a stroke could linger for decades.

Although the stroke mortality rate is declining in the U.S., statistics find that about 14% of all patients diagnosed with an initial stroke will have a second one within a year, placing continued strain on a healthcare system already stretched thin.⁶ Hospitalists, Dr. Lackland says, have an “ideal” opportunity to help build up and improve that system, potentially yielding significant cost savings along with the dramatic improvement in quality of life. Making the most of that opportunity, though, will require a solid understanding of multiple trends that are quickly transforming stroke care delivery.

Time Is of the Essence

Kevin Barrett, MD, MSc, assistant professor of neurology and stroke telemedicine director at the Mayo Clinic in Jacksonville, Fla., says hospitals are focusing more and more on a metric known as “door-to-needle time.” The goal is to treat at least half of incoming ischemic stroke patients with intravenous tissue-type plasminogen activator (IV tPA) within the first 60 minutes after onset of symptoms.

The American Heart Association/American Stroke Association has reinforced the message with its Get With the Guidelines Stroke Program. A recent analysis suggested the program has led to more timely tPA administration and, in turn, better patient outcomes (the program is funded in part through the Bristol-Myers Squib/Sanofi Pharmaceutical Partnership).⁷

 

At the same time, clinical research has widened the window for IV tPA delivery from three hours to 4.5 hours for certain patients after the onset of symptoms. Dr. Barrett says “strong evidence” from the European Cooperative Acute Stroke Study III has convinced most clinicians, and the FDA is expected to follow suit in officially approving the extension.⁸ As more stroke centers become certified, the use of IV tPA has increased accordingly.

Patients who have missed the time window or are not good candidates for IV tPA can still be aided by interarterial tPA at the site of the clot up to six hours after the onset of symptoms. Dr. Likosky says the treatment option should be of particular interest to hospitalists, given that strokes can occur post-operatively and in other patients who cannot receive IV tPA because of bleeding risk.

For up to eight hours after the onset of symptoms, mechanical clot removal techniques have shown continued efficacy at revascularizing affected areas, with some newer options also offering greater promise of improving patient outcomes. Even with the prospects of declining complication rates, however, “evaluating and initiating treatment in a timely fashion is still going to be one of the most important predictors of outcome,” Dr. Barrett says.

After the initial intervention, hospitalists often are the go-to providers for anticipating and preventing common post-stroke complications, such as aspiration pneumonia, VTE from immobilization, and other infections. The proper use of anti-platelet agents and high-dose statins, also falling solidly within the HM realm, can pay big dividends if used consistently.

Meanwhile, newer studies and clinical observations are widening the scope of considerations that should be on every hospitalist’s radar. Here are a few cited by stroke experts:

Permissive hypertension. After an ischemic stroke, the benefit of permissive hypertension is still widely misunderstood. Perhaps counterintuitively, high blood pressure after a stroke can help protect the area of the brain that is damaged but not yet dead, sometimes called the penumbra. “I highlight this because I think it’s a common mistake, that internists are very used to high blood pressure being a bad thing,” says Andrew Josephson, MD, associate professor of clinical neurology and director of the neurohospitalist program at the University of California at San Francisco (UCSF) Medical Center. “And in general, it is; it’s a cause of stroke. But once somebody has a stroke, in the acute period, it’s important to allow the blood pressure to be high.”

Atrial fibrillation. The accepted role of atrial fibrillation in stroke is evolving. Research suggests that the common but often preventable arrhythmia is an important cause of stroke in about 15% to 20% of cases.⁹ By the time of hospital discharge, however, Dr. Josephson says physicians haven’t established a cause in about 1 in 4 cases. For these “cryptogenic strokes,” he says, doctors have long suspected that atrial fibrillation not picked up during the initial EKG or by the monitoring with cardiac telemetry could be a major cause.

Recent observations suggest that a longer monitoring period of up to 30 days may uncover atrial fibrillation in a sizable fraction of those patients, highlighting the importance of keeping a close eye on stroke patients both in the hospital and beyond. “It’s very important to identify, because atrial fibrillation changes what we do for folks to prevent a second stroke,” Dr. Josephson explains. Instead of anti-platelet medicine like aspirin, patients with atrial fibrillation often receive anticoagulants like warfarin, or the more recently approved dabigatran and rivaroxaban.

 

Transient ischemic attack. Improvements in imaging techniques like MRI have likewise begun to shift how stroke patients are treated. For example, Dr. Likosky says, medicine is moving away from a time-based definition of transient ischemic attack (TIA), in which symptoms resolve within 24 hours, to a tissue-based definition. Recent MRI imaging has uncovered evidence of a new infarction in more than half of patients initially diagnosed with TIA.¹⁰

“If they do have an infarction on their scan, even if they had symptoms that only lasted for five minutes, that’s a stroke,” Dr. Josephson says. And even a true TIA, he says, represents “a kind of stroke where you got really lucky and you’re not left with deficits, but the risk is still very high.” Accordingly, more patients with TIA are being admitted to the hospital to receive a full workup and preventive treatment. “We think that by evaluating these people urgently, we can reduce the risk of having a stroke by maybe 75% over a three-month time period,” Dr. Josephson says.

Hemorrhagic stroke. To date, the vast majority of patients with hemorrhagic stroke (which accounts for only 13% of all stroke cases) have been managed by neurosurgeons and neurologists. But here, too, Dr. Likosky says the picture could be changing. Recent findings that surgical treatment of intracranial hemorrhaging might not benefit many patients could shift the care paradigm toward a medical management strategy that involves more hospitalists.

Innovations Aplenty

The increasing complexity of stroke care and uneven distribution of resources and expertise have helped fuel several important innovations in delivery, most notably telestroke and neurohospital medicine. Both are being driven, in part, by an increased awareness of time-sensitive interventions and a frequent lack of on-site neurologists at smaller and more rural facilities. If telestroke programs are expanding the reach of neurologists, neurohospitalists are helping to fill the gaps in inpatient stroke care.

Amid the changes, one element is proving a necessary constant: a team approach that relies heavily on the HM emphasis on quality metrics, intensive monitoring, and careful coordination. Who better to lead the charge than hospitalists, says Mary E. Jensen, MD, professor of radiology and neurosurgery at the University of Virginia in Charlottesville. “They’re the ones who are in the hospital, and when these patients go bad, they go bad fast,” she says.

More broadly, Dr. Jensen says, hospitalists should get in on the ground floor when their facility seeks certification as a primary or a comprehensive stroke center. “And they need to make sure that the hospital isn’t just trying to get the sexy elements—the guy with the cath or the gal with the cath who can pull the clot out—but that they have a complete program that involves the care of the patient after they’ve had the procedure done,” she says.

As healthcare reform efforts are making clear, the responsibility doesn’t end after discharge, either. The Affordable Care Act includes a hospital readmission reduction program that will kick in this October, with penalties for hospitals posting unacceptably high 30-day readmission rates. Amy Kind, MD, PhD, assistant professor of medicine in the Division of Geriatrics at the University of Wisconsin School of Medicine and Public Health in Madison, is convinced that a key contributor to high rehospitalization rates among stroke patients may be the woefully incomplete nature of discharge communication.

 

Dr. Kind, for example, has found a disturbing pattern in communication regarding issues like dysphagia, a common complication among stroke patients and an important risk factor for pneumonia. Countering the risk usually requires such measures as putting patients on a special diet or elevating the head of their bed. “We looked at the quality of the communication of that information in discharge summaries, and it’s just abysmal. It’s absolutely abysmal,” she says. Without clear directives to providers in the next setting of care, such as a skilled-nursing facility, patients could be erroneously put back on a regular diet and aspirate, sending them right back to the hospital.

As one potential solution, Dr. Kind’s team is developing a multidisciplinary stroke discharge summary tool that automatically imports elements like speech-language pathology and dietary recommendations. Although most discharge communication may focus on more visible issues and interventions, Dr. Kind argues that some of the “bread and butter” concerns might ultimately prove just as important for long-term patient outcomes.

Karim Godamunne, MD, MBA, SFHM, vice president of clinical systems integration and medical director of Eagle Hospital Physicians in Atlanta, sees telemedicine as another potential tool to help reach patients after discharge, especially those who haven’t received follow-up care from a primary-care physician (PCP). “We need to be the champions at our hospitals for improving care processes, and we need to work in partnership with the nurses and the other professionals,” Dr. Godamunne says. “As a group, we can really make a difference, and stroke is one of those areas in which we can truly contribute.”

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Freeman WD, Dawson SB, Raper C, Thiemann K, et al. Neurohospitalists reduce length of stay for patients with ischemic stroke. The Neurohospitalist. 2011;1(2): 67-70.
2. Howrey BT, Kuo Y-F, Goodwin JS. Association of care by hospitalists on discharge destination and 30-day outcomes after acute ischemic stroke. Medical Care. 2011;49(8): 701-707.
3. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation. 2012;125:e2-e220.
4. Glasheen JJ, Epstein KR, Siegal E, Kutner JS, Prochazka AV. The spectrum of community-based hospitalist practice: a call to tailor internal medicine residency training. Arch Intern Med. 2007;167(7):727-728.
5. Plauth WH, Pantilat SZ, Wachter RM, Fenton CL. Hospitalists’ perceptions of their residency training needs: results of a national survey. Am J Med. 2001; 111(3):247-254.
6. Dickerson LM, Carek PJ, Quattlebaum RG. Prevention of recurrent ischemic stroke. Am Fam Physician. 2007; 76(3):382-388.
7. Fonarow GC, Smith EE, Saver JL, et al. Timeliness of tissue-type plasminogen activator therapy in acute ischemic stroke: patient characteristics, hospital factors, and outcomes associated with door-to-needle times within 60 minutes. Circulation. 2011;123(7):750-758.
8. Hacke W, Kaste M, Bluhmki E, Brozman M, et al. Thrombolysis with Alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359:1317-1329.
9. Lloyd-Jones D, Adams RJ, Brown TM, et al. Heart disease and stroke statistics—2010 update: a report from the American Heart Association. Circulation. 2010;121:e91.
10. Albers GW, Caplan LR, Easton JD, et al. Transient ischemic attack—proposal for a new definition. N Engl J Med. 2002;347(21):1713-1716.
11. Chimowitz MI, Lynn MJ, Derdeyn CP, et al. Stenting versus aggressive medical therapy for intracranial arterial stenosis. N Engl J Med. 2011;365:993-1003.

Stroke specialists like to say that “time is brain.” With an emphatic focus on those first few critical hours, however, it’s sometimes easy to overlook the vital role that hospitalists play in the days, weeks, and months that follow.

A recent study in The Neurohospitalist suggests that compared to community-based neurologists, practitioners of neurohospital medicine can reduce the length of stay for patients with ischemic stroke.¹ A separate study, however, suggests that similar success might have come at a price for their less-specialized hospitalist counterparts.² Among stroke patients, the latter study found that while the HM model is also associated with a reduced length of stay, it is associated with increased discharges to inpatient rehabilitation centers instead of to home, and higher readmission rates.

In sum, the evidence raises questions about whether rank-and-file hospitalists are adequately equipped to deal with a disease that is a core competency for the profession and ranks among the top sources of adult disability in the United States, at an estimated cost of $34.3 billion in 2008.³

“I think there’s been a mismatch between the training of the average hospitalist and then the expectations for the amount of neurological care they end up delivering once in practice,” says David Likosky, MD, SFHM, director of the stroke program at Evergreen Hospital Medical Center in Kirkland, Wash. “When surveyed, it’s been shown that hospitalists feel that care of stroke is one of the areas with which they’re least comfortable once they get out into practice.” Over the past decade, several studies have reinforced the notion of a training deficit.^4,5

Demographic trends suggest that getting up to speed will be imperative, however. “One alarming thing we’re seeing is strokes among individuals that are not in the elderly group, and that group seems to be increasing at an alarming rate,” says Daniel T. Lackland, PhD, professor of epidemiology and neurosciences at the Medical University of South Carolina in Charleston. Hospitals are seeing more ischemic stroke patients in their 40s and 50s, likely a reflection of risk factors such as hypertension, diabetes, and hyperlipidemia that are occurring earlier in life. And because those patients are younger, the aftermath of a stroke could linger for decades.

Although the stroke mortality rate is declining in the U.S., statistics find that about 14% of all patients diagnosed with an initial stroke will have a second one within a year, placing continued strain on a healthcare system already stretched thin.⁶ Hospitalists, Dr. Lackland says, have an “ideal” opportunity to help build up and improve that system, potentially yielding significant cost savings along with the dramatic improvement in quality of life. Making the most of that opportunity, though, will require a solid understanding of multiple trends that are quickly transforming stroke care delivery.

Time Is of the Essence

Kevin Barrett, MD, MSc, assistant professor of neurology and stroke telemedicine director at the Mayo Clinic in Jacksonville, Fla., says hospitals are focusing more and more on a metric known as “door-to-needle time.” The goal is to treat at least half of incoming ischemic stroke patients with intravenous tissue-type plasminogen activator (IV tPA) within the first 60 minutes after onset of symptoms.

The American Heart Association/American Stroke Association has reinforced the message with its Get With the Guidelines Stroke Program. A recent analysis suggested the program has led to more timely tPA administration and, in turn, better patient outcomes (the program is funded in part through the Bristol-Myers Squib/Sanofi Pharmaceutical Partnership).⁷

 

At the same time, clinical research has widened the window for IV tPA delivery from three hours to 4.5 hours for certain patients after the onset of symptoms. Dr. Barrett says “strong evidence” from the European Cooperative Acute Stroke Study III has convinced most clinicians, and the FDA is expected to follow suit in officially approving the extension.⁸ As more stroke centers become certified, the use of IV tPA has increased accordingly.

Patients who have missed the time window or are not good candidates for IV tPA can still be aided by interarterial tPA at the site of the clot up to six hours after the onset of symptoms. Dr. Likosky says the treatment option should be of particular interest to hospitalists, given that strokes can occur post-operatively and in other patients who cannot receive IV tPA because of bleeding risk.

For up to eight hours after the onset of symptoms, mechanical clot removal techniques have shown continued efficacy at revascularizing affected areas, with some newer options also offering greater promise of improving patient outcomes. Even with the prospects of declining complication rates, however, “evaluating and initiating treatment in a timely fashion is still going to be one of the most important predictors of outcome,” Dr. Barrett says.

After the initial intervention, hospitalists often are the go-to providers for anticipating and preventing common post-stroke complications, such as aspiration pneumonia, VTE from immobilization, and other infections. The proper use of anti-platelet agents and high-dose statins, also falling solidly within the HM realm, can pay big dividends if used consistently.

Meanwhile, newer studies and clinical observations are widening the scope of considerations that should be on every hospitalist’s radar. Here are a few cited by stroke experts:

Permissive hypertension. After an ischemic stroke, the benefit of permissive hypertension is still widely misunderstood. Perhaps counterintuitively, high blood pressure after a stroke can help protect the area of the brain that is damaged but not yet dead, sometimes called the penumbra. “I highlight this because I think it’s a common mistake, that internists are very used to high blood pressure being a bad thing,” says Andrew Josephson, MD, associate professor of clinical neurology and director of the neurohospitalist program at the University of California at San Francisco (UCSF) Medical Center. “And in general, it is; it’s a cause of stroke. But once somebody has a stroke, in the acute period, it’s important to allow the blood pressure to be high.”

Atrial fibrillation. The accepted role of atrial fibrillation in stroke is evolving. Research suggests that the common but often preventable arrhythmia is an important cause of stroke in about 15% to 20% of cases.⁹ By the time of hospital discharge, however, Dr. Josephson says physicians haven’t established a cause in about 1 in 4 cases. For these “cryptogenic strokes,” he says, doctors have long suspected that atrial fibrillation not picked up during the initial EKG or by the monitoring with cardiac telemetry could be a major cause.

Recent observations suggest that a longer monitoring period of up to 30 days may uncover atrial fibrillation in a sizable fraction of those patients, highlighting the importance of keeping a close eye on stroke patients both in the hospital and beyond. “It’s very important to identify, because atrial fibrillation changes what we do for folks to prevent a second stroke,” Dr. Josephson explains. Instead of anti-platelet medicine like aspirin, patients with atrial fibrillation often receive anticoagulants like warfarin, or the more recently approved dabigatran and rivaroxaban.

 

Transient ischemic attack. Improvements in imaging techniques like MRI have likewise begun to shift how stroke patients are treated. For example, Dr. Likosky says, medicine is moving away from a time-based definition of transient ischemic attack (TIA), in which symptoms resolve within 24 hours, to a tissue-based definition. Recent MRI imaging has uncovered evidence of a new infarction in more than half of patients initially diagnosed with TIA.¹⁰

“If they do have an infarction on their scan, even if they had symptoms that only lasted for five minutes, that’s a stroke,” Dr. Josephson says. And even a true TIA, he says, represents “a kind of stroke where you got really lucky and you’re not left with deficits, but the risk is still very high.” Accordingly, more patients with TIA are being admitted to the hospital to receive a full workup and preventive treatment. “We think that by evaluating these people urgently, we can reduce the risk of having a stroke by maybe 75% over a three-month time period,” Dr. Josephson says.

Hemorrhagic stroke. To date, the vast majority of patients with hemorrhagic stroke (which accounts for only 13% of all stroke cases) have been managed by neurosurgeons and neurologists. But here, too, Dr. Likosky says the picture could be changing. Recent findings that surgical treatment of intracranial hemorrhaging might not benefit many patients could shift the care paradigm toward a medical management strategy that involves more hospitalists.

Innovations Aplenty

The increasing complexity of stroke care and uneven distribution of resources and expertise have helped fuel several important innovations in delivery, most notably telestroke and neurohospital medicine. Both are being driven, in part, by an increased awareness of time-sensitive interventions and a frequent lack of on-site neurologists at smaller and more rural facilities. If telestroke programs are expanding the reach of neurologists, neurohospitalists are helping to fill the gaps in inpatient stroke care.

Amid the changes, one element is proving a necessary constant: a team approach that relies heavily on the HM emphasis on quality metrics, intensive monitoring, and careful coordination. Who better to lead the charge than hospitalists, says Mary E. Jensen, MD, professor of radiology and neurosurgery at the University of Virginia in Charlottesville. “They’re the ones who are in the hospital, and when these patients go bad, they go bad fast,” she says.

More broadly, Dr. Jensen says, hospitalists should get in on the ground floor when their facility seeks certification as a primary or a comprehensive stroke center. “And they need to make sure that the hospital isn’t just trying to get the sexy elements—the guy with the cath or the gal with the cath who can pull the clot out—but that they have a complete program that involves the care of the patient after they’ve had the procedure done,” she says.

As healthcare reform efforts are making clear, the responsibility doesn’t end after discharge, either. The Affordable Care Act includes a hospital readmission reduction program that will kick in this October, with penalties for hospitals posting unacceptably high 30-day readmission rates. Amy Kind, MD, PhD, assistant professor of medicine in the Division of Geriatrics at the University of Wisconsin School of Medicine and Public Health in Madison, is convinced that a key contributor to high rehospitalization rates among stroke patients may be the woefully incomplete nature of discharge communication.

 

Dr. Kind, for example, has found a disturbing pattern in communication regarding issues like dysphagia, a common complication among stroke patients and an important risk factor for pneumonia. Countering the risk usually requires such measures as putting patients on a special diet or elevating the head of their bed. “We looked at the quality of the communication of that information in discharge summaries, and it’s just abysmal. It’s absolutely abysmal,” she says. Without clear directives to providers in the next setting of care, such as a skilled-nursing facility, patients could be erroneously put back on a regular diet and aspirate, sending them right back to the hospital.

As one potential solution, Dr. Kind’s team is developing a multidisciplinary stroke discharge summary tool that automatically imports elements like speech-language pathology and dietary recommendations. Although most discharge communication may focus on more visible issues and interventions, Dr. Kind argues that some of the “bread and butter” concerns might ultimately prove just as important for long-term patient outcomes.

Karim Godamunne, MD, MBA, SFHM, vice president of clinical systems integration and medical director of Eagle Hospital Physicians in Atlanta, sees telemedicine as another potential tool to help reach patients after discharge, especially those who haven’t received follow-up care from a primary-care physician (PCP). “We need to be the champions at our hospitals for improving care processes, and we need to work in partnership with the nurses and the other professionals,” Dr. Godamunne says. “As a group, we can really make a difference, and stroke is one of those areas in which we can truly contribute.”

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Freeman WD, Dawson SB, Raper C, Thiemann K, et al. Neurohospitalists reduce length of stay for patients with ischemic stroke. The Neurohospitalist. 2011;1(2): 67-70.
2. Howrey BT, Kuo Y-F, Goodwin JS. Association of care by hospitalists on discharge destination and 30-day outcomes after acute ischemic stroke. Medical Care. 2011;49(8): 701-707.
3. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation. 2012;125:e2-e220.
4. Glasheen JJ, Epstein KR, Siegal E, Kutner JS, Prochazka AV. The spectrum of community-based hospitalist practice: a call to tailor internal medicine residency training. Arch Intern Med. 2007;167(7):727-728.
5. Plauth WH, Pantilat SZ, Wachter RM, Fenton CL. Hospitalists’ perceptions of their residency training needs: results of a national survey. Am J Med. 2001; 111(3):247-254.
6. Dickerson LM, Carek PJ, Quattlebaum RG. Prevention of recurrent ischemic stroke. Am Fam Physician. 2007; 76(3):382-388.
7. Fonarow GC, Smith EE, Saver JL, et al. Timeliness of tissue-type plasminogen activator therapy in acute ischemic stroke: patient characteristics, hospital factors, and outcomes associated with door-to-needle times within 60 minutes. Circulation. 2011;123(7):750-758.
8. Hacke W, Kaste M, Bluhmki E, Brozman M, et al. Thrombolysis with Alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359:1317-1329.
9. Lloyd-Jones D, Adams RJ, Brown TM, et al. Heart disease and stroke statistics—2010 update: a report from the American Heart Association. Circulation. 2010;121:e91.
10. Albers GW, Caplan LR, Easton JD, et al. Transient ischemic attack—proposal for a new definition. N Engl J Med. 2002;347(21):1713-1716.
11. Chimowitz MI, Lynn MJ, Derdeyn CP, et al. Stenting versus aggressive medical therapy for intracranial arterial stenosis. N Engl J Med. 2011;365:993-1003.

Stroke specialists like to say that “time is brain.” With an emphatic focus on those first few critical hours, however, it’s sometimes easy to overlook the vital role that hospitalists play in the days, weeks, and months that follow.

A recent study in The Neurohospitalist suggests that compared to community-based neurologists, practitioners of neurohospital medicine can reduce the length of stay for patients with ischemic stroke.¹ A separate study, however, suggests that similar success might have come at a price for their less-specialized hospitalist counterparts.² Among stroke patients, the latter study found that while the HM model is also associated with a reduced length of stay, it is associated with increased discharges to inpatient rehabilitation centers instead of to home, and higher readmission rates.

In sum, the evidence raises questions about whether rank-and-file hospitalists are adequately equipped to deal with a disease that is a core competency for the profession and ranks among the top sources of adult disability in the United States, at an estimated cost of $34.3 billion in 2008.³

“I think there’s been a mismatch between the training of the average hospitalist and then the expectations for the amount of neurological care they end up delivering once in practice,” says David Likosky, MD, SFHM, director of the stroke program at Evergreen Hospital Medical Center in Kirkland, Wash. “When surveyed, it’s been shown that hospitalists feel that care of stroke is one of the areas with which they’re least comfortable once they get out into practice.” Over the past decade, several studies have reinforced the notion of a training deficit.^4,5

Demographic trends suggest that getting up to speed will be imperative, however. “One alarming thing we’re seeing is strokes among individuals that are not in the elderly group, and that group seems to be increasing at an alarming rate,” says Daniel T. Lackland, PhD, professor of epidemiology and neurosciences at the Medical University of South Carolina in Charleston. Hospitals are seeing more ischemic stroke patients in their 40s and 50s, likely a reflection of risk factors such as hypertension, diabetes, and hyperlipidemia that are occurring earlier in life. And because those patients are younger, the aftermath of a stroke could linger for decades.

Although the stroke mortality rate is declining in the U.S., statistics find that about 14% of all patients diagnosed with an initial stroke will have a second one within a year, placing continued strain on a healthcare system already stretched thin.⁶ Hospitalists, Dr. Lackland says, have an “ideal” opportunity to help build up and improve that system, potentially yielding significant cost savings along with the dramatic improvement in quality of life. Making the most of that opportunity, though, will require a solid understanding of multiple trends that are quickly transforming stroke care delivery.

Time Is of the Essence

Kevin Barrett, MD, MSc, assistant professor of neurology and stroke telemedicine director at the Mayo Clinic in Jacksonville, Fla., says hospitals are focusing more and more on a metric known as “door-to-needle time.” The goal is to treat at least half of incoming ischemic stroke patients with intravenous tissue-type plasminogen activator (IV tPA) within the first 60 minutes after onset of symptoms.

The American Heart Association/American Stroke Association has reinforced the message with its Get With the Guidelines Stroke Program. A recent analysis suggested the program has led to more timely tPA administration and, in turn, better patient outcomes (the program is funded in part through the Bristol-Myers Squib/Sanofi Pharmaceutical Partnership).⁷

 

At the same time, clinical research has widened the window for IV tPA delivery from three hours to 4.5 hours for certain patients after the onset of symptoms. Dr. Barrett says “strong evidence” from the European Cooperative Acute Stroke Study III has convinced most clinicians, and the FDA is expected to follow suit in officially approving the extension.⁸ As more stroke centers become certified, the use of IV tPA has increased accordingly.

Patients who have missed the time window or are not good candidates for IV tPA can still be aided by interarterial tPA at the site of the clot up to six hours after the onset of symptoms. Dr. Likosky says the treatment option should be of particular interest to hospitalists, given that strokes can occur post-operatively and in other patients who cannot receive IV tPA because of bleeding risk.

For up to eight hours after the onset of symptoms, mechanical clot removal techniques have shown continued efficacy at revascularizing affected areas, with some newer options also offering greater promise of improving patient outcomes. Even with the prospects of declining complication rates, however, “evaluating and initiating treatment in a timely fashion is still going to be one of the most important predictors of outcome,” Dr. Barrett says.

After the initial intervention, hospitalists often are the go-to providers for anticipating and preventing common post-stroke complications, such as aspiration pneumonia, VTE from immobilization, and other infections. The proper use of anti-platelet agents and high-dose statins, also falling solidly within the HM realm, can pay big dividends if used consistently.

Meanwhile, newer studies and clinical observations are widening the scope of considerations that should be on every hospitalist’s radar. Here are a few cited by stroke experts:

Permissive hypertension. After an ischemic stroke, the benefit of permissive hypertension is still widely misunderstood. Perhaps counterintuitively, high blood pressure after a stroke can help protect the area of the brain that is damaged but not yet dead, sometimes called the penumbra. “I highlight this because I think it’s a common mistake, that internists are very used to high blood pressure being a bad thing,” says Andrew Josephson, MD, associate professor of clinical neurology and director of the neurohospitalist program at the University of California at San Francisco (UCSF) Medical Center. “And in general, it is; it’s a cause of stroke. But once somebody has a stroke, in the acute period, it’s important to allow the blood pressure to be high.”

Atrial fibrillation. The accepted role of atrial fibrillation in stroke is evolving. Research suggests that the common but often preventable arrhythmia is an important cause of stroke in about 15% to 20% of cases.⁹ By the time of hospital discharge, however, Dr. Josephson says physicians haven’t established a cause in about 1 in 4 cases. For these “cryptogenic strokes,” he says, doctors have long suspected that atrial fibrillation not picked up during the initial EKG or by the monitoring with cardiac telemetry could be a major cause.

Recent observations suggest that a longer monitoring period of up to 30 days may uncover atrial fibrillation in a sizable fraction of those patients, highlighting the importance of keeping a close eye on stroke patients both in the hospital and beyond. “It’s very important to identify, because atrial fibrillation changes what we do for folks to prevent a second stroke,” Dr. Josephson explains. Instead of anti-platelet medicine like aspirin, patients with atrial fibrillation often receive anticoagulants like warfarin, or the more recently approved dabigatran and rivaroxaban.

 

Transient ischemic attack. Improvements in imaging techniques like MRI have likewise begun to shift how stroke patients are treated. For example, Dr. Likosky says, medicine is moving away from a time-based definition of transient ischemic attack (TIA), in which symptoms resolve within 24 hours, to a tissue-based definition. Recent MRI imaging has uncovered evidence of a new infarction in more than half of patients initially diagnosed with TIA.¹⁰

“If they do have an infarction on their scan, even if they had symptoms that only lasted for five minutes, that’s a stroke,” Dr. Josephson says. And even a true TIA, he says, represents “a kind of stroke where you got really lucky and you’re not left with deficits, but the risk is still very high.” Accordingly, more patients with TIA are being admitted to the hospital to receive a full workup and preventive treatment. “We think that by evaluating these people urgently, we can reduce the risk of having a stroke by maybe 75% over a three-month time period,” Dr. Josephson says.

Hemorrhagic stroke. To date, the vast majority of patients with hemorrhagic stroke (which accounts for only 13% of all stroke cases) have been managed by neurosurgeons and neurologists. But here, too, Dr. Likosky says the picture could be changing. Recent findings that surgical treatment of intracranial hemorrhaging might not benefit many patients could shift the care paradigm toward a medical management strategy that involves more hospitalists.

Innovations Aplenty

The increasing complexity of stroke care and uneven distribution of resources and expertise have helped fuel several important innovations in delivery, most notably telestroke and neurohospital medicine. Both are being driven, in part, by an increased awareness of time-sensitive interventions and a frequent lack of on-site neurologists at smaller and more rural facilities. If telestroke programs are expanding the reach of neurologists, neurohospitalists are helping to fill the gaps in inpatient stroke care.

Amid the changes, one element is proving a necessary constant: a team approach that relies heavily on the HM emphasis on quality metrics, intensive monitoring, and careful coordination. Who better to lead the charge than hospitalists, says Mary E. Jensen, MD, professor of radiology and neurosurgery at the University of Virginia in Charlottesville. “They’re the ones who are in the hospital, and when these patients go bad, they go bad fast,” she says.

More broadly, Dr. Jensen says, hospitalists should get in on the ground floor when their facility seeks certification as a primary or a comprehensive stroke center. “And they need to make sure that the hospital isn’t just trying to get the sexy elements—the guy with the cath or the gal with the cath who can pull the clot out—but that they have a complete program that involves the care of the patient after they’ve had the procedure done,” she says.

As healthcare reform efforts are making clear, the responsibility doesn’t end after discharge, either. The Affordable Care Act includes a hospital readmission reduction program that will kick in this October, with penalties for hospitals posting unacceptably high 30-day readmission rates. Amy Kind, MD, PhD, assistant professor of medicine in the Division of Geriatrics at the University of Wisconsin School of Medicine and Public Health in Madison, is convinced that a key contributor to high rehospitalization rates among stroke patients may be the woefully incomplete nature of discharge communication.

 

Dr. Kind, for example, has found a disturbing pattern in communication regarding issues like dysphagia, a common complication among stroke patients and an important risk factor for pneumonia. Countering the risk usually requires such measures as putting patients on a special diet or elevating the head of their bed. “We looked at the quality of the communication of that information in discharge summaries, and it’s just abysmal. It’s absolutely abysmal,” she says. Without clear directives to providers in the next setting of care, such as a skilled-nursing facility, patients could be erroneously put back on a regular diet and aspirate, sending them right back to the hospital.

As one potential solution, Dr. Kind’s team is developing a multidisciplinary stroke discharge summary tool that automatically imports elements like speech-language pathology and dietary recommendations. Although most discharge communication may focus on more visible issues and interventions, Dr. Kind argues that some of the “bread and butter” concerns might ultimately prove just as important for long-term patient outcomes.

Karim Godamunne, MD, MBA, SFHM, vice president of clinical systems integration and medical director of Eagle Hospital Physicians in Atlanta, sees telemedicine as another potential tool to help reach patients after discharge, especially those who haven’t received follow-up care from a primary-care physician (PCP). “We need to be the champions at our hospitals for improving care processes, and we need to work in partnership with the nurses and the other professionals,” Dr. Godamunne says. “As a group, we can really make a difference, and stroke is one of those areas in which we can truly contribute.”

Bryn Nelson is a freelance medical writer in Seattle.

References

1. Freeman WD, Dawson SB, Raper C, Thiemann K, et al. Neurohospitalists reduce length of stay for patients with ischemic stroke. The Neurohospitalist. 2011;1(2): 67-70.
2. Howrey BT, Kuo Y-F, Goodwin JS. Association of care by hospitalists on discharge destination and 30-day outcomes after acute ischemic stroke. Medical Care. 2011;49(8): 701-707.
3. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation. 2012;125:e2-e220.
4. Glasheen JJ, Epstein KR, Siegal E, Kutner JS, Prochazka AV. The spectrum of community-based hospitalist practice: a call to tailor internal medicine residency training. Arch Intern Med. 2007;167(7):727-728.
5. Plauth WH, Pantilat SZ, Wachter RM, Fenton CL. Hospitalists’ perceptions of their residency training needs: results of a national survey. Am J Med. 2001; 111(3):247-254.
6. Dickerson LM, Carek PJ, Quattlebaum RG. Prevention of recurrent ischemic stroke. Am Fam Physician. 2007; 76(3):382-388.
7. Fonarow GC, Smith EE, Saver JL, et al. Timeliness of tissue-type plasminogen activator therapy in acute ischemic stroke: patient characteristics, hospital factors, and outcomes associated with door-to-needle times within 60 minutes. Circulation. 2011;123(7):750-758.
8. Hacke W, Kaste M, Bluhmki E, Brozman M, et al. Thrombolysis with Alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359:1317-1329.
9. Lloyd-Jones D, Adams RJ, Brown TM, et al. Heart disease and stroke statistics—2010 update: a report from the American Heart Association. Circulation. 2010;121:e91.
10. Albers GW, Caplan LR, Easton JD, et al. Transient ischemic attack—proposal for a new definition. N Engl J Med. 2002;347(21):1713-1716.
11. Chimowitz MI, Lynn MJ, Derdeyn CP, et al. Stenting versus aggressive medical therapy for intracranial arterial stenosis. N Engl J Med. 2011;365:993-1003.