Hospitalists? Post-Acute Care Utilization Is Rising, Resulting in Rapidly Increasing Costs

ANALYSIS KEY CLINICAL QUESTION IN THE LITERATURE Post-acute care: Transfusing ppatientsatients Prescribe antibiotics LTC quality report cards with aanemianemia wisely PAGE 16 PAGE 28 PAGE 40

VOLUME 21 NO. 12 I DECEMBER 2017 AN OFFICIAL PUBLICATION OF THE SOCIETY OF HOSPITAL MEDICINE How will SNF readmissions penalties affect hospitalists? Post-acute care utilization is rising, resulting in rapidly increasing costs

By Larry Beresford

tarting in 2018, skilled nurs- Sing facilities (SNFs), like acute care hospitals before them, will be subject to a penalty of up to 2% of their Medicare reimbursement for posting higher-than-average rates of readmissions. Managing mental health The Protecting Access to Medi- care Act of 2014 established a value- based purchasing component for SNFs, including incentives for high- care at the hospital performing facilities and a measure for all-cause, all-condition readmissions to any hospital from the SNF Care integration is more of an attitude than a system within 30 days following hospital discharge – designed to recognize By Suzanne Bopp shrinking resources are the other. Mental health resources had and reward, or punish, facilities’ already been diminishing for decades before the recession hit – performance on preventing unnec- he numbers tell a grim story. Nationwide, 43.7 million and hit them especially hard. Between 2009 and 2012, states essary readmissions. Public report- T adult Americans experienced a mental health condition cut $5 billion in mental health services; during that time, at ing of SNF quality data, including during 2016 – an increase of 1.2 million over the previ- least 4,500 public psychiatric hospital beds nationwide disap- readmission rates, started in October ous year. Mental health issues send almost 5.5 million people peared – nearly 10% of the total supply. The bulk of those 2017. Penalties follow a year later. to emergency departments each year; nearly 60% of adults resources have never been restored. Some patients’ readmissions could with a mental illness received no treatment at all. Provider numbers also are falling. “Psychiatry is prob- trigger penalties for both the hospi- If that massive – and growing – need is one side of the story, CONTINUED ON PAGE 25 tal and the SNF. According to 2010 data, 23.5% of patients discharged from acute care hospitals to SNFs were readmitted to the hospital within 30 days, at a financial cost of $10,362 per readmission A LOVE OF or $4.34 billion per year.1 Seventy Q&A eight percent of these readmissions TEACHING were labeled avoidable. More recent evidence suggests that hospitalization rates for dual-eligible patients living in James Kim, MD long-term care facilities decreased by P. 13 31% between 2010 and 2015.2

As increasing numbers of hospitalists

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THE HOSPITALIST HOSPITALIST THE CHANGE SERVICE REQUESTED SERVICE CHANGE CONTINUED ON PAGE 18 SOCIETY PAGES I News and information about SHM

Building a better SHM Volume 21 Number 12 December 2017 PHYSICIAN EDITOR THE SOCIETY OF HOSPITAL MEDICINE Danielle B. Scheurer, MD, SFHM, MSCR Phone: 800-843-3360 New HMX platform and website are highlights [email protected] Fax: 267-702-2690 Website: www.HospitalMedicine.org PEDIATRIC EDITOR By Brett Radler SHM emails, we urge you to opt back in Weijen Chang, MD, FAAP, SFHM Laurence Wellikson, MD, MHM, CEO [email protected] Lisa Zoks to receive information on your local chap- Vice President of Marketing & COORDINATING EDITORS s we enter the holiday season, the ter meetings and more targeted messages Communications Society of Hospital Medicine is about SHM offerings tailored specifically Christine Donahue, MD [email protected] A THE FUTURE HOSPITALIST preparing to unwrap a refreshed to your interests. 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6 THE HOSPITALIST I DECEMBER 2017 I www.the-hospitalist.org SOCIETY PAGES I News and information about SHM EVERYTHING WE SAY AND DO: Adopting the patient’s perspective Take time to communicate, express concern

By Larry Sharp, MD, SFHM that made me uncomfortable, not knowing demeanor was nice enough, but she did not who they were and why they were in my even attempt to make a personal connection Editor’s note: “Everything We Say and Do” room. Not knowing is an uncomfortable with me – and she was at the welcome desk! provides readers with thoughtful and action- feeling for a patient. Overall, I had tremendously good expe- able communication tactics that can posi- Almost every registered nurse who came riences at three facilities in three different tively impact patients’ experience of care. In to me with medication explained what the parts of the United States, but as we all the current series of columns, physicians share medicine was and why they were administer- know, it is the things that do not go well how their experiences as patients have shaped ing it, with the exception of one preop RN that stand out. I choose to use those things, their professional approach. I met before to my cataract procedure. She along with some of the good things, as “rein- walked up to me, told me to open my eye forcers” for many of the patient-experience have been fortunate to have had very few wide, held the affected eye open, and started behaviors we identify as best practices. Imajor health issues throughout my life. I dripping cold drops into my eye without have, however, had three major surgical explanation. She then said she would be What I say and do procedures in the last 10 years – two total back every 10 minutes to repeat the process. During each patient encounter, I make eye hip arthroplasties and a cataract removal I had to inquire as to what the medication contact with the patient and each person in with lens implant in between. The most was and why there was a need for this process. the room and identify who I am and why I Dr. Sharp is chief hospitalist with recent THA was October 2017. Going It was a jolting experience, and she showed am there. I sit down during each visit unless Sound Physicians at University of through each procedure helped me see no compassion toward me as a patient or a there is simply no place for me to do so. Florida Health in Jacksonville. things from a patient’s perspective, and that person, even after I inquired. I explain the procedures that are to take showed me how important little things are This was not a good experience. Although place, set expectations for those procedures, to a patient, things which we may not think cataract surgery was a totally new experience and then use “teachback” to ensure that my are all that big a deal as a provider. for me, she had obviously done this many discussion with the patient has been effec- courtesy and respect. These practices show a For example, during my first total hip times before and had to do it many times tive. Setting expectations is very important willingness to take time with the patient and arthroplasty, the surgeon took time to sit that day. However, she acted as if I should to me: If you do not ensure that patients demonstrate my concern that I am effectively down in the room during each visit. He have known what she was going to do and have appropriate expectations, their expec- communicating my message for that visit. All continued to write in the chart periodically as if she need not explain herself to anyone – tations will never be met and they will never of these behaviors decrease uncertainty and/ while we spoke, but he was sitting while which she did not, even after being queried. have a good experience. I explain any new or raise the patient’s feelings of importance, doing it. I could not believe the difference Everyone during the admission process medication I am ordering, what it is for, thereby decreasing marginalization. in how that made me feel about his visits! for all three procedures was solicitous and and any possible significant side effects and I felt like he was taking his time, and it put warm except for one person. Unfortunately, again use teachback. The last thing I do is How I do it me more at ease. I knew what he was doing this individual was the first person to greet ask “What questions do you have for me I remind myself each day I am on a clinical and why he was doing it (I had been preach- my wife and me when we arrived for my last today?” giving the patient permission to shift that my goal is to treat each patient ing it to my team for years), and yet, it still total hip arthroplasty. She was seated at the have questions, and then I respond to those like I would want my family (or myself) made a difference to me. welcome desk with her head down. After we questions with plain talk and teachback. to be treated, and then I go out and do it. Almost all of the medical personnel who arrived, she kept her head down and asked After “forcing” myself to put these behav- came to care for me during my stays identi- “How can I help you?” without ever look- Why I do it iors into my rounding routine, they have fied themselves and why they were there, ing up. I did not realize how unwelcome I Not knowing what was going on and feel- become second nature, and I feel better for and that made me feel comfortable, know- would feel when the first person I encoun- ing marginalized were the most uncomfort- providing this level of care because it made ing who they were and their role. However, tered in the surgical preop admissions area able things I experienced as a patient. Using me feel so good when I was cared for in there were a few who did not do this, and failed to make eye contact with me. Her best practices for patient experience shows this manner.

NEWS & NOTES

The latest news, events, medicine at your fingertips by participat- The collaborative also offers numerous Develop your career at programs, and SHM ing. As a thank-you for your participation, resources, including training materials, Hospital Medicine 2018 your group will receive a free copy of the project management and process improve- hDon’t miss SHM’s Annual Conference, initiatives. report. Sign up at hospitalmedicine.org/ ment tools for hospitals to use to adapt Hospital Medicine 2018, to be held April survey. for their needs to improve the medication 8-11, 2018. in Orlando. This year, the By Brett Radler reconciliation process. Visit hospitalmedi- program was created to help you develop Apply for SHM’s MARQUIS cine.org/MARQUISrecruit to learn more. your hospital medicine career, no matter State of Hospital Medicine Med Rec Collaborative what stage you are in. Two new tracks Survey opens next month! kicking off in February 2018 Get engaged with public policy include Seasoning Your Career and the h The 2018 State of Hospital Medicine hSHM’s MARQUIS Med Rec Collabo- h Health care legislation is constantly Career Development Workshops. Survey will begin in January and last rative is designed to help hospitals across evolving, and hospitalists play an impor- Seasoning Your Career focuses on didac- through March with the release of the the United States implement evidence- tant role in advocating for hospitalized tics designed to augment those commit- report in September 2018. Whether based best practice medication recon- patients and the hospital medicine move- ted to a career in hospital medicine, you are in a hospital medicine group ciliation process change and improvement. SHM is an active voice in many including topics such as career growth in an academic or community setting, ment. The collaborative is a 14-month conversations on policy development and development, resiliency, work-life employed by a hospital or health system, program, spanning from prelaunch to and reform. Visit hospitalmedicine.org balance, and how practical work matters a management company, a private group, completion. and sign up for the Grassroots Network such as schedules affect your career. or you serve adult or pediatric patients (or The staff has the expertise and experi- to stay updated on developments in health The new Career Development Work- both), we need your participation. ence of having completed two previous care policy, share your experiences with shops track includes six sessions that aim Help us help you have the most compre- mentored implementation studies, involv- health care programs and participate in to help you use skills that will advance hensive, up-to-date landscape of hospital ing 23 sites and thousands of patients. policy forums. CONTINUED ON PAGE 12

www.the-hospitalist.org I DECEMBER 2017 I THE HOSPITALIST 7 SOCIETY PAGES I News and information about SHM The Hospital Leader blog SNEAK PEEK It’s time to bring women leaders to the forefront

By Vineet Arora, MD, MPP, MHM resulted in only one in five professors who sial challenges that require careful thought: news is that education on stereotype are female, I wondered whether there were • Stereotype threat: Some of the original threat apparently helps. Cultivating women leaders hidden figures – women leaders among us research on stereotype threat done in • Impostor syndrome: Even highly success- in health care #WIMmonth who we don’t see. college students showed that, if women ful people apparently suffer from impos- #ThisIsWhatADoctorLooksLike Turns out I wasn’t the only one who who are about to take a math test are told tor syndrome, the fear that they do not On my flight home from Scotland, I had a stumbled upon this. Harvard researcher that the test will expose gender differ- deserve their success, but it is much worse in moment to watch a movie while my daugh- Julie Silver, MD, raised the question about ences, such as men do better at math, women than in men. You are always trying ter was caught up in the encore adventures invisible women leaders when reviewing women will perform worse AND men to conquer the little voice in your head that of Moana. I stum- quotes in magazines like Modern Health- will do better. The threat of stereotypes tells you that you are not good enough. bled upon “Hidden care or Forbes. Moreover, her research is that women can internalize them and Figures,” the story of demonstrates that, for many professional this may hamper their progress. The good Read the full post at hospitalleader.org. the African American society awards, 0% are given to women! women at NASA who This is happening in specialties that had helped launch John nearly even proportions of women and men Glenn into space, in practice, such as dermatology and rehab ALSO ON THE HOSPITAL reviving the nation’s medicine. Last month, I was dumbfounded LEADER BLOG space program. when I saw a full-page New York Times ad These women were Dr. Arora of Top Surgeons by Castle Connolly featur- true heroes and patri- ing 16 surgeons, all male. POST: If I were you, I would not be bullish on long-term care by Brad ots – they lived in a man’s world and a white While Castle Connolly does name female Flansbaum, DO, MPH, MHM world, and they still managed to overcome top doctors and market ad opportunities to and lead when needed. Yet, their story was women and men, I learned that only men POST: Da Vinci wuz here by Jordan Messler, MD, SFHM “hidden” from the public until years later sign up for the ads. While this raises more when popularized into this screenplay. On questions, the optics remain problematic – POST: Making the implicit explicit by Leslie Flores, MHA, SFH the plane, I realized I needed a fresh take to women doctors are hidden. Regardless of start my women in medicine webinar for the venue, we must do a better job profiling POST: Should we really focus on “patient-centered care”? by Tracy this month’s American Medical Associa- our female leaders. In addition, it is impor- Cardin, ACNP-BC, SFHM tion Women in Medicine webinar. Instead tant to recognize that female leaders face of exploring the “leaky pipeline” that well-documented and somewhat controver- Journal of Hospital Medicine SNEAK PEEK Trends in troponin-only testing for AMI in academic teaching hospitals and the impact of Choosing Wisely®

By Micah T. Prochaska, MD, PATIENTS: Hospitalized patients with a MS; Samuel F. Hohmann, PhD, principal discharge diagnosis of AMI. MS-HSM; Matthew Modes, MD, ALSO IN JHM MPH; and Vineet Arora, MD, INTERVENTION: The Choosing Wisely® THIS MONTH MPP, MHM recommendation to order troponin-only testing to diagnose AMI was released BACKGROUND: Identifying hospitals that during the first quarter of 2015. Hospital perceptions of Medicare’s Sepsis are both early and consistent adopters of Quality Reporting Initiative high-value care can help shed light on the RESULTS: In 19 hospitals, troponin- AUTHORS: Ian J. Barbash, MD, MS; Kimberly J. Rak, PhD; Courtney C. Kuza, MPH; and culture and practices at those institutions only testing was consistently ordered Jeremy M. Kahn, MD, MS that are necessary to promote high-value to diagnose AMI before the Choosing care nationwide. The use of troponin test- Wisely® recommendation and through- ing to diagnose acute myocardial infarc- out the study period. In 34 hospitals, Health literacy and hospital length of tion (AMI), and not testing for myoglo- both troponin testing and myoglobin/ stay: An inpatient cohort study bin or creatine kinase-MB (CK-MB), CK-MB testing were ordered to diag- AUTHORS: Ethan G. Jaffee, MD; Vineet Arora, MD, MAPP; Madeleine I. Matthiesen, MD; David is a high-value recommendation of the nose AMI even after the Choosing O. Meltzer, MD, PhD, MHM; and Valerie G. Press, MD, FAAP, FACP, MPH Choosing Wisely® campaign. Wisely® recommendation. In 26 hospitals with low rates of troponin-only OBJECTIVE: To examine the variation in testing before the Choosing Wisely® How exemplary teaching physicians cardiac biomarker testing and the effect of recommendation, the release of the interact with hospitalized patients the Choosing Wisely® troponin-only testing recommendation was associated with a AUTHORS: Sanjay Saint, MD, MPH, FHM; Molly Harrod, PhD; Karen E. Fowler, MPH; and recommendation for the diagnosis of AMI. statistically significant increase in the Nathan Houchens, MD, FACP, FHM rate of troponin-only testing to diag- DESIGN: A retrospective, observational nose AMI. study using administrative ordering A randomized cohort controlled trial to compare data from Vizient’s Clinical Database/ CONCLUSION: In institutions with low intern sign-out training interventions Resource Manager. rates of troponin-only testing prior to AUTHORS: Soo-Hoon Lee, PhD; Christopher Terndrup, MD; Phillip H. Phan, PhD; Sandra E. the Choosing Wisely® recommendation, Zaeh, MD; Kwame Atsina, MD; Nicole Minkove, MD; Alexander Billioux, MD; DPhil, Souvik SETTING: Chatterjee, MD; Idoreyin Montague, MD; Bennett Clark, MD; Andrew Hughes, MD; and Sanjay Ninety-one academic medical the recommendation was associated V. Desai, MD centers from the fourth quarter of 2013 with a significant increase in the rate of through the third quarter of 2016. troponin-only testing.

8 THE HOSPITALIST I DECEMBER 2017 I www.the-hospitalist.org QI ENTHUSIAST TO QI LEADER: Sheri Chernetsky Tejedor, MD Research, informatics, and patient care intersect

By Eli Zimmerman quality course at Emory that mirrored it.” Frontline Medical News Dr. Tejedor’s research evolved to intersect with clinical informatics. She leveraged the Trained as an engineer, rmed with a background in engineer- organization’s electronic medical record to Aing, Sheri Chernetsky Tejedor, MD, test her work. Dr. Sheri Chernetsky SFHM, had already adopted a mind- “[The EMR] is ubiquitous, and that was set of system reliability and design improve- a good way to reach staff, test interventions, Tejedor says knowledge ment when she began her journey in hospi- and get data,” Dr. Tejedor said. “I built a tal medicine at Johns Hopkins University lot of tools that were helpful for the health of informatics and the in Baltimore. system.” After completing her studies there, Dr. One of these tools was a device to moni- business of medicine is Tejedor was quick to find a place at Emory tor central line infections that was linked Healthcare in Atlanta and began work- with clinical informatics as part of a large key to institutional quality ing toward a future in health care quality grant project. This led to another leadership improvement. improvement (QI). opportunity: She assumed the role of chief “I gravitated early on toward what was research information officer and director essentially quality improvement work,” Dr. for analytics at Emory Healthcare in 2013. Tejedor told The Hospitalist. In 2014, Dr. Tejedor began working Dr. Tejedor worked with two mentors with the Centers for Disease Control and at a community hospital associated with Prevention as the first hospitalist and infor- Emory University who helped influence matics specialist on the Healthcare Infec- her success in QI: Mark V. Williams, MD, tion Control Practices Advisory Commit- FACP, MHM, who is now the director of tee, where she continues to hold a position. the Center for Health Services Research She is also a medical adviser for the CDC’s at the University of Kentucky in Lexing- Division of Healthcare Quality Promotion, ton, and Jason Stein, MD, SFHM, who is focusing on electronic quality measures. currently a hospitalist at Emory University For those hospitalists pursuing QI, Hospital. exposure to formal training is essential, Dr. “They wanted to develop quality Tejedor said. That may not mean flying to a doctor taking care of patients,” she said. and getting to know the leadership and the improvement expertise and get some of Utah, she noted, but garnering a deeper “Learn just enough to understand what goes people who make the financial decisions,” us trained,” she said. “These advocates, understanding of informatics is crucial. into people’s decision making when they are she said. “Even if you have the money for a or mentors, were critical for me. They are When it comes to leadership, Dr. Teje- choosing what projects get approved.” quality improvement project, it will fail if people who went above and beyond to help dor recommends that those looking to take Dr. Tejedor encourages hospitalists to you don’t work with the various teams to with career planning and thinking through charge develop social skills and embrace focus on developing relationships because understand their needs and how to make it possibilities.” parts of medicine that may be unfamiliar that was one of the keys to her success as a work for them.” Dr. Tejedor and Dr. Stein traveled to yet essential. quality improvement leader. Intermountain Healthcare, a not-for-profit “Learn a little bit about the business side, “It’s about gaining the trust of the staff, [email protected] health system based in Salt Lake City that which you may not know much about as mutual respect, working with the nurses, On Twitter @eaztweets focuses on medical innovation, to participate in a rigorous quality training program. “It was extremely intense,” said Dr. Teje- dor. “You worked over several months to get a certificate from the Institute for Health- care Delivery Research, and it’s all focused on quality improvement methodology.” After completing this program, Dr. Teje- dor continued on her quality improvement path by focusing on research while also simultaneously working part time and taking care of her three young children. During this phase of her career, Dr. Teje- dor and her colleagues published a study on idle central venous catheters, which became a primary reference for part of the ABIM Foundation’s Choosing Wisely® campaign. Dr. Tejedor said that, in addition to research, she explored different leadership roles, such as taking charge of central line teams and nurses working on device inser- tion practices. Her successful projects drew notice, and soon Dr. Tejedor and Dr. Stein helped to implement a stronger focus on quality improvement at their organization. “Our health system was very entrenched in that QI culture,” Dr. Tejedor said. “After Jason and I went to Intermountain, many of the Emory Healthcare leadership also got trained in Utah, and we ultimately built a

www.the-hospitalist.org I DECEMBER 2017 I THE HOSPITALIST 9 HOSP_10_11.indd 2 11/10/2017 11:16:32 AM HOSP_10_11.indd 3 11/10/2017 11:17:42 AM SOCIETY PAGES I News and information about SHM Homelessness: Whose job is it? We need better ways of addressing vulnerability among homeless patients

By Sarah A. Stella, MD, FHM Homelessness is associated with myriad needs, perspectives and preferences of adverse health consequences, including a homeless individuals with respect to hospi- espite programs to end homeless- high burden of acute and chronic diseases, tal discharge. Homeless patients often face Dness, it remains a substantial and high rates of mental illness and substance significant obstacles on discharge, includ- growing problem in many cities in use, increased utilization of emergency ing lack of safe housing and respite options, the United States.1,2 In 2016, there were and hospital services, decreased utilization lack of transportation, and lack of social an estimated 10,550 homeless people of primary care, and an increased risk of support.13 Lack of integration between living in my home state of Colorado, a death.4-8 Homeless adults who are hospi- hospitals and community organizations 6% increase from the prior year.2 A recent talized represent a particularly vulner- further exacerbates these problems. point-estimate study found that there able group affected disproportionately Addressing the significant known health were more than 5,000 homeless individ- by morbidity and mortality.9,10 In fact, disparities faced by homeless persons is one uals in the Denver metropolitan area on a previous research indicates that almost of the greatest health equity challenges of our single night in January 2017.3 Because of half of adult super-utilizers – patients who time.14 We need better ways of understand- the relative scarcity of housing, a growing accumulate multiple emergency depart- ing, identifying, and addressing vulnerability number of cities like Denver now utilize ment visits and hospital admissions – are among homeless patients who are hospital- a practice known as vulnerability index- homeless.11 In addition to homelessness, ized, paired with improved integration with ing to prioritize homeless persons at high this group is characterized by high rates local community organizations. This will Dr. Stella is a hospitalist at Denver risk of mortality from medical conditions of multiple chronic health conditions and require moving beyond the idea that home- Health and Hospital Authority, and an for placement in permanent supportive mental health and substance use disorders. lessness is the social worker’s job to one of associate professor of medicine at housing.4 Although hospitalists like myself shared responsibility and advocacy. the University of Colorado. She is a frequently care for vulnerable homeless Collaborative research and other partner- member of The Hospitalist editorial patients in the hospital, most have little ships that engage both community organi- advisory board. What can formal training in how best to care for zations and individuals affected by home- and advocate for these individuals beyond lessness are crucial to further understand utilization of homeless persons. JAMA. 2001;285(2):200-6. treating their acute medical need, and little the specific needs, barriers, challenges, and hospitalists do to 7. Kushel MB et al. Emergency department use among the direct contact with community organiza- opportunities for improving hospital care homeless and marginally housed: Results from a commu- tions with expertise in doing so. Instead, we and care transitions in this population. As nity-based study. Am J Public Health. 2002;92(5):778-84. improve the care of have learned informally through experience. well-respected community members and 8. Baggett TP et al. Mortality among homeless adults in Hospital providers are often frustrated by the systems thinkers who witness these ineq- Boston: Shifts in causes of death over a 15-year period. homeless patients? JAMA Intern Med. 2013 Feb 11;173(3):189-95. perceived lack of services and support avail- uities on a daily basis, hospitalists are well 9. Johnson et al. For many patients who use large amounts able to these patients, and there is substantial positioned to help lead this work. of health care services, the need is intense yet temporary. Ask: Ask questions to better variability in the extent to which providers Health Aff (Millwood). 2015 Aug;34(8):1312-9. understand patients’ housing engage patients and community partners References 10. Durfee J et al. The impact of tailored intervention 1. Ending Chronic Homelessness. (Aug 2017). U.S. Intera- services on charges and mortality for adult super-utilizers. status and needs. during and after hospitalization. Despite Healthc (Amst). 2017 Aug 25. pii: S2213-0764(17)30057-X. Learn: Educate yourself on the the growing practice of vulnerability index- gency Council on Homelessness. Available at https://www. usich.gov/goals/chronicsness. Accessed Oct 21, 2017. doi: 10.1016/j.hjdsi.2017.08.004. [Epub ahead of print]. full range of respite, housing, ing in the community, hospital-based provid- 11. Rinehart DJ et al. Identifying subgroups of adult super 2. 2016 Annual Homeless Assessment Report (AHAR) to utilizers in an urban safety-net system using latent class and other support services ers do not routinely assess vulnerability with Congress. (Nov 2016). U.S. Department of Housing and analysis: Implications for clinical practice. Med Care. 2016 Urban Development Office of Community Planning and available to homeless patients in respect to housing. Previous research indi- Sep 14. doi: 10.1097/MLR.0000000000000628. [Epub Development, Part 1. Available at https://www.hudex- your community. cates that housing status is assessed in only ahead of print]. Advocate: change.info/resources/documents/2016-AHAR-Part-1. Get involved in commu- a minority of homeless patients during their pdf. Accessed Oct 21, 2017. 12. Greysen RS et al. Understanding transitions of care 12 from hospital to homeless shelter: A mixed-methods, nity organizations that advocate hospital stay. Thus, hospitalization often 3. 2017 Point-In-Time Report, Seven-County Metro Denver community-based participatory approach. J Gen Intern Region. Metro Denver Homeless Initiative. Available at http:// for policies benefiting those represents a missed opportunity to identify Med. 2012;27(11):1484-91. www.mdhi.org/2017_pit. Accessed Oct 22, 2017. affected by homelessness. vulnerability and utilize it to connect patients 13. National Health Care for the Homeless Council. (Oct Lead: Spearhead collaborative with housing and other resources. 4. Henwood BF et al. Examining mortality among formerly 2012). Improving Care Transitions for People Experienc- research and other partnerships Despite the development of best prac- homeless adults enrolled in Housing First: An observational ing Homelessness. (Lead author: Sabrina Edgington, policy study. BMC Public Health. 2015;15:1209. and program specialist.) Available at www.nhchc.org/ aimed at improving hospital care tices and ongoing research on interven- 5. Weinstein LC et al. Moving from street to home: Health wp-content/uploads/2012/12/Policy_Brief_Care_Transi- and care transitions for vulner- tions to improve care transitions in various status of entrants to a Housing First program. J Prim Care tions.pdf. Accessed Oct 21, 2017. able homeless persons. groups, there is limited research specifi- Community Health. 2011;2:11-5. 14. Koh HK et al. Improving healthcare for homeless people. cally focused on understanding the unique 6. Kushel MB et al. Factors associated with the health care JAMA. 2016;316(24):2586-7.

NEWS & NOTES

CONTINUED FROM PAGE 7 ing Committee, which includes nation- sionally, network with colleagues nation- colleagues, and stay current on the latest ally recognized hospitalists with expertise wide, and shape the practice of hospital developments in hospital medicine. your career, such as: Leadership Essentials in scholarship, career development, and medicine. See a full list of member bene- Visit hospitalmedicine.org/chapters to for Success in Hospital Medicine; Being medical education, this track aims to fits or become a member today at hospi- find a chapter in your area. Female in Hospital Medicine: Overcom- inspire future hospitalist leaders. talmedicine.org/join. ing Individual and Institutional Barriers in Visit shmannualconference.org/sched- Two new modules debut on the Workplace; Do You Have a Minute to ule to learn more. Join a chapter and connect SHM’s Learning Portal Talk? Peer-to-Peer Feedback, and more. to your local hospital h SHM members have access to free Just starting out in hospital medicine? Not a member? Join the medicine community continuing medical education (CME) Back by popular demand, The Early- movement today hSHM hosts more than 50 local chap- and Maintenance of Certification (MOC) Career Hospitalists track has been designed hMore than 15,000 members have joined ters nationwide to encourage networking, points with the SHM Learning Portal. for new hospitalists, resident physi- SHM to show their commitment to revo- collaboration, and innovation within the Don’t miss two new modules: Role of the cians, and medical students interested in lutionizing patient care. As a member, you hospital medicine community. Getting Medical Consultant and Anesthesia for pursuing a career in hospital medicine. will be connected with a wealth of oppor- involved with your local chapter allows Internists. Designed by SHM’s Physicians-in-Train- tunities designed to help you grow profes- you to share knowledge, engage with Medical consultation is an important

12 THE HOSPITALIST I DECEMBER 2017 I www.the-hospitalist.org TEAM HOSPITALIST I Q&A with our newest editorial advisory board members A love of teaching: Q&A James Kim, MD Dr. Kim joins The Hospitalist editorial advisory board

By Eli Zimmerman I want to try to contribute ideas. I feel that even in my Frontline Medical News short time at Emory, I’ve gotten to know a few people hile James Kim, MD, did not orig- Winally begin medical school with a who might be good resources for reporters to interview plan to become a hospitalist, he has embraced his current role wholeheartedly. or even who might write articles themselves. I also think Since becoming board certified in both internal medicine and infectious diseases, that seeing what is trending in the world of hospital medi- Dr. Kim has welcomed the opportunity to cine is a nice way of understanding the future direction of be part of hospital medicine, which enables him to pursue his other passion: teaching hospital medicine. and mentoring. As an assistant professor of medicine at Emory University in Atlanta, Dr. Kim –James Kim, MD has tried to emulate his own mentors by not simply distributing factual information to students but also teaching ways of thinking. A: When I finished my internal medi- situation in which we are not necessarily are going to come up about how do we “It’s not just what you know but how cine residency, I thought I was going to do doing medical work for a patient but are manage a health care system as compli- you convey what you know to other medical missions. However, I realized along doing something more like social work. For cated as America’s and how do we deliver people,” said Dr. Kim. “While you might the way that the care you need to provide instance, there are cases in which patients optimal care to people especially when get useful information from a didactic in order to really make a difference in other cannot be on their own in the community, sometimes we end up in situations in teaching style, it’s important to ask ques- countries requires a constant presence there and there’s no family to take them in, so which we don’t have all the resources that tions to encourage the learner to think – not just a week or two. So after my fellow- the hospital, on behalf of the state, has to we would want to have because of circum- about not only what the right answer ship, I was searching for jobs and found take them in. stances. is but also what’s the thought process a hospitalist position at the University of required to get the answer.” California, Los Angeles. When I saw it, I Q: What else do you do outside of Q: Do you see anything in particular As one of the newest additions to the thought “Wow, I really miss doing inpa- hospitalist work? on the horizon for hospital medicine? editorial advisory board of The Hospitalist, tient medicine.” A: Since I’ve finished medical school, I’ve A: I’ve noticed that there’s been more Dr. Kim took time to tell us more about always been in some kind of academia, “hospitalist-ization” – if that’s even a himself in a recent interview. Q: Since you started, what have been which is not something I would have term – of other medical services. At our some of your favorite parts of hospital expected. But as time has gone by, I have institution, we already have an acute care QUESTION: How did you nd your medicine? really come to appreciate being in academia. service that is basically hospital medicine career path in medicine? A: When people come to you in the hospi- I really enjoy teaching, and I also think that for general surgery. I think another thing ANSWER: I originally went into medi- tal setting, they are usually pretty sick. It is an academic institution kind of keeps me that’s been kind of a hot topic recently is a cal school thinking I was going to do very satisfying when, through the course of on my toes. I’m involved with interprofes- point-of-care testing, including ultrasounds pediatrics, but then I realized that I really a person’s hospital stay, we are able to come sional education at Emory, with teaching for line placements. enjoy talking to people and that I like the up with a plan that can get them acutely medical students, interns, and residents process of thinking through diagnoses, better. when I’m on teaching service, and obvi- Q: Where do you see yourself in 10 managing patients, and learning about ously now I’m on The Hospitalist edito- years? what makes their circumstances unique. Q: What do you think is the hardest rial board. I’m looking forward to keeping A: I really enjoy my work at Emory. I want part of hospital medicine? abreast of what’s hot in the world of hospi- to find more opportunities to teach. For Q: How did you get into hospital A: I think one of the things that is most tal medicine. example, I’ve already gotten involved in medicine? frustrating is when we are placed into a teaching physician assistant students about Q: What are you excited about bring- how to perform interviews and deliver pres- ing to The Hospitalist editorial board? entations for attendings. A lot of serendipi- A: I want to try to contribute ideas. I feel tous things have happened to me over time, NEWS & NOTES that, even in my short time at Emory, I’ve so I think I will continue to teach, but I’m gotten to know a few people who might be open to those opportunities that present good resources for reporters to interview or themselves in the future. clinical component for most hospital- for Internists module discusses the basic even who might write articles themselves. ists. Today, hospitalists also are asked forms of surgical anesthesia and contrain- I also think that seeing what is trending Q: What’s the best book you’ve read to provide both “curbside” advice and dications to each, as well as the most in the world of hospital medicine is a nice recently and why? more comprehensive comanagement commonly used anesthetic drugs, their way of understanding the future direction A: “The Hero with a Thousand Faces,” of medical problems. Hospitalists who mechanisms of actions, and side effects. of hospital medicine. by Joseph Campbell. This is a very well- are effective consultants communicate Both modules are free for SHM known book – I think George Lucas made skillfully and act professionally. The members and $45.00 per module for Q: What have you seen as being the reference to it when he was writing Star Role of the Medical Consultant module nonmembers. Earn 2 AMA PRA Cate- biggest change in hospital medicine Wars – but I think it was a great literary describes the different roles that hospi- gory 1 Credits™ and 2 MOC points per since you started? way to examine the hero’s journey. Once talists can perform as medical consult- each module. Visit shmlearningportal. A: I feel as though I’ve kept my head down you read the book, and you then watch ants and provides strategies for improv- org to get started today. and plowed forward through the first part any kind of movie or read any other kind ing communications and referring of my career, but I think that, more than of adventure narrative, you can’t miss the physician satisfaction. Mr. Radler is marketing communications anything else, what I’ve noticed is bigger pattern. Looking for up-to-date information manager at the Society of Hospital shifts within health care itself. I know that about surgical anesthesia? The Anesthesia Medicine. there’s a lot of consolidation going on. I [email protected] think that there are many questions that On Twitter @eaztweets

www.the-hospitalist.org I DECEMBER 2017 I THE HOSPITALIST 13 PUBLIC POLICY I Issues critical for hospitalists Hospitals will feel the squeeze of DSH payment changes Rule could mean loss of quality physicians, services

By Kelly April Tyrrell “Inner city, safety-net hospitals are always fighting for a piece of the pie. arlier this year, the Centers for Medi- Their payer mix is more favorable, yet they game the system for these Ecare & Medicaid Services finalized fundamental changes to how it reim- funds.” burses hospitals for uncompensated care costs. When first proposed, the move –Bradley Flansbaum, DO, MPH, MHM raised alarm among physicians, hospitals, health systems, state health departments, and others around the country, and even prompted a lawsuit in New Hampshire. “I think the reason it’s contentious is because, when you’re dealing with In the months since the official adop- tion by the CMS, it remains unclear how a fixed dollar amount and you’re talking about redistributing dollars, the change will affect hospitals around the country, particularly the safety-net hospitals someone is going to lose.” that rely on these payments most. The rule alters the formula previously –John McHugh, PhD used to determine Disproportionate Share Hospital (DSH) payments, meant to fill in the gap for those hospitals treating large numbers of Medicaid and uninsured practice in more challenged settings.2 ing their practices. It could mean loss of government is the only entity that seems to patients. The change is a reinterpretation In a letter to the CMS, the Minnesota services. It could mean the loss of quality win across the board, Dr. McHugh said. He of regulations that the CMS says have been Department of Human Services said it physicians and quality staffing, and that can said he would not be surprised if analysts codified but unenforced since the Omnibus agrees with the agency that DSH payments impact patient care.” looked to see how hospitals were affected Budget Reconciliation Act of 1993, that say should not be used to “subsidize costs that by it in coming months. the agency will reimburse DSH-qualified have been paid by Medicare and other How will hospitals adapt? But, he remains optimistic. In fact, the hospitals for the uncompensated costs they insurers” but disagrees with the agency’s The CMS did not give hospitals transition final rule also came with an $800 million incur providing care (inpatient and outpa- approach. Its argument includes a challenge time. The reinterpretation became effective increase in the amount of uncompensated tient) to Medicaid-eligible and uninsured to the CMS’s statutory authority to change in June 2017, just 60 days after the agency care payments for acute care hospitals in patients. The agency argues that payments the formula based on existing language.3 issued the final rule. Dr. McHugh said he fiscal year 2018, the CMS says.4 made on behalf of these same patients by “I think the reason it’s contentious is is not sure why the agency did not build “Hospitals are adaptable,” Dr. McHugh Medicare, the patients themselves, and because, when you’re dealing with a fixed in time for hospitals to adapt, particularly said. “I think what you’ll see is this will spur other third-party party payers should be dollar amount and you’re talking about redis- given the uncertainty around the national some innovation in terms of patient care considered revenue and not contribute to tributing dollars, someone is going to lose,” uninsured rate going forward, with so many maybe a few years down the road. It may hit individual hospitals’ DSH limits. Previ- said John McHugh, PhD, professor of health potential changes to the American health some stumbling blocks in the early going ously, the CMS primarily based payments management at the Mailman School of care system under a new administration. but there may be some positive changes in on the number of Medicaid and uninsured Public Health at Columbia University, New How any of these changes trickle down the future.” patients any given hospital treated.1 York. “A facility receiving DSH payments is to hospitalists remains to be seen, said Dr. In its final rule issued in April 2017 already dealing with high levels of uncom- Flansbaum. Dr. McHugh believes it could References and finalized on Aug. 2, 2017, the federal pensated care; the hospitals are operating lead to increased patient loads, higher 1. Medicaid Program; Disproportionate Share Hospital Payments –Treatment of Third Party Payers in Calculating agency said the intent of the change is on very thin margins. They are very often turnover and churn, and fewer experienced Uncompensated Care Costs. Centers for Medicare & Medic- to more fairly distribute a fixed amount getting by because of these payments.” physicians in safety-net hospitals as younger aid Services final rule. Citation 82 FR 16114. Published April of DSH funds to the hospitals most in Despite the CMS’s seemingly good inten- doctors are hired and burn out. “At the end 3, 2017. Last accessed Aug 14, 2017. https://www.feder- alregister.gov/documents/2017/04/03/2017-06538/medic- need. It also argued the change is a more tions, Bradley Flansbaum, DO, MPH, of the day, that feeds into patient care and aid-program-disproportionate-share-hospital-payments- consistent interpretation of the existing MHM, a hospitalist at Geisinger Health patient satisfaction and quality,” he said. treatment-of-third-party-payers-in. statute [Section 1923(g)], provides clarifi- System and member of the SHM Public However, hospitals across the country 2. Kugler E. 2016-09-14 NAUH Medicaid Program DSH cation around language that has been the Policy Committee, remains skeptical that have been living with this “slow burn” for Payments – Treatment of Third Party Payer in Calcu- lating Uncompensated Care Costs. Sep 14, 2016. Last subject of inquiry over the last decade, and the hospitals that need and deserve DSH a long time, said Dr. Flansbaum, though accessed Aug 14, 2017. https://www.regulations.gov/ promotes what it calls “fiscal integrity.” payments will actually see more redistrib- not necessarily due to inadequate DSH document?D=CMS-2016-0144-0020. “These allotments essentially establish a uted in their favor. payments. At least in some areas, reimburse- 3. Berg A. Proposed Rule on Disproportionate Share Hospital finite pool of available federal DSH funds “Inner city, safety-net hospitals are always ments have gone down, hospital occupancy Payments – Treatment of Third Party Payers in Calculating Uncompensated Care Costs, CMS-2399-P. Sep 14, 2016. that states use to pay the federal portion of fighting for a piece of the pie,” he said, noting rates have declined, rural hospitals have Last accessed Aug 14, 2017. https://www.regulations.gov/ payments to all qualifying hospitals in each that a percentage of larger health systems and closed, hospitals have consolidated, and document?D=CMS-2016-0144-0046. state,” the final rule reads. “As states often midsized hospitals also take advantage of people have been laid off. 4. CMS finalizes 2018 payment and policy updates for use most or all of their federal DSH allot- DSH payments. “Their payer mix is more It’s important to ensure the hospitals Medicare hospital admissions. Published Aug 2, 2017. Last accessed Aug 14, 2017. https://www.cms.gov/News- ment, in practice, if one hospital gets more favorable, yet they game the system for these providing care for high levels of uninsured room/MediaReleaseDatabase/Press-releases/2017-Press- DSH funding, other DSH-eligible hospi- funds,” Dr. Flansbaum added. or underinsured patients receive the help releases-items/2017-08-02.html. tals in the state may get less.” If hospitals in need see fewer DSH they need, he said, and it’s also important to This is not, however, the way all parties see dollars, Dr. McHugh noted, they will feel examine the role hospitals play as a whole it. For instance, in a comment submitted to the squeeze. in the American health care system. the CMS in September 2016, the National “It’s not easy to operate safety-net hospi- “It’s an expensive system,” he said. Association of Urban Hospitals expressed tals,” he said. “And on top of that, hospi- “We have created a system where, unlike its concern that DSH payments already are tals have been operating under a certain other countries that have developed inadequate to cover the financial burden assumption and it’s changing, and it takes more vigorous primary or outpatient associated with providing care in low-income time to incorporate those changes. There care, we have created an inpatient communities, such as translation services will probably be some fallout for the first health system.” and the costs of employing physicians to couple of years as hospitals are adapt- With the CMS’s change, the

georgenight777/Thinkstock 14 THE HOSPITALIST I DECEMBER 2017 I www.the-hospitalist.org DOES YOUR CURIOSITY KEEP YOU UP AT NIGHT? It does that to us too. CEP America’s democratic practice model is designed to encourage your curiosity. We empower our providers to improve the patient experience, rethink work-life balance, and transform their practice.

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HOSP_15.indd 1 11/16/2017 7:58:50 PM ANALYSIS Using post-acute and long-term care quality report cards Discharge planning decisions fall heavily on patients, families, caregivers

By Charlene Harrington, PhD, reduce length of stay.9 A focus on identifying within and across states ranging from one RN; Leslie Ross, PhD; and Jeffrey the first available nursing home bed or LTC star (poorest quality) to five stars (highest Newman, MD, MPH provider often ignores the need to identify quality). More than one-third of nursing the most appropriate high-quality providers. homes had relatively low overall star ratings he challenges of hospital discharge Although individuals on Medicaid and/or (one or two stars) serving 39% of residents Tplanning are well known and yet with complex medical conditions may have in 2015.11 Federal nursing home regulatory have not been adequately addressed fewer discharge options than other patients, violations range from 0 to more than 40 by hospitalists and discharge teams. As the the majority of nursing home providers have deficiencies (average of 7) with a scope and complexity of patient care needs has grown, low occupancy rates and will accept residents severity ranging from minor to widespread so has the difficulty in developing appropri- from any payer. Other home- and commu- harm or jeopardy (including deaths).12 Total ate discharge goals for post-acute and long- nity-based providers generally have a flexible nurse staffing hours (average, 4.1 hours per term care (LTC), choosing the appropriate capacity for serving individuals. resident-day) range from less than 3 hours setting(s), and selecting appropriate provid- Hospitals and health plans often have to more than 5.5 hours per resident-day and ers. Post-acute and LTC needs may include established networks of post-acute and LTC RN hours are 3.5 times higher in some nurs- rehabilitation, nursing care, home health, providers and these networks must be taken ing homes than in the lowest staffed homes.13 supportive services, and/or palliative care1 into account in the discharge process. Most Hospital readmission rates for short-stay resi- in an institutional setting or at home from hospital and health plan networks have dents from nursing homes also vary widely a wide array of providers with varying levels providers with a wide range of ratings, allow- (4%-52%; average, 21%).1,12 of quality. ing for choices within networks. Hospitalists and discharge planners should Even though 52% of U.S. hospitals The Centers for Medicare & Medicaid inform patients, families, and caregivers received penalties for having higher-than- Services established a web-based nursing about the federal and state LTC quality expected readmissions between 2013 and home report card called Nursing Home report cards, provide education and choices, 2017,2 inadequate discharge planning for Compare in 1998 that includes information and engage and assist them in the decision- post-acute and LTC continues to contribute on facility characteristics, deficiencies, staff- making process. Hospitals, health plans, and to high rates of all-cause 30-day rehospitali- ing information (since 2000), and resident accountable care organizations also need to zation. The discharge process sometimes is quality indicators (since 2002). In 2008, the be more informed about the availability of deficient in discussion of goals; assessment website added a “five-star” rating system for and benefits of using quality report cards of discharge needs; appropriate choice of all U.S. nursing homes and all-cause 30-day for developing post-acute and LTC provider discharge locations; and the provision of readmission rates and successful discharge networks. The use of high-quality LTC additional or different home services.3 rates from nursing homes were incorporated network providers should be able to reduce Discharge decisions are complicated by the into the ratings in 2016. hospital length of stay and hospital readmis- stressful circumstances of hospitalization and CMS also established a web-based home sion rates, and improve patient and caregiver discharge deadlines. health website, which provides quality satisfaction. A number of intervention studies have ratings. This website has general informa- been implemented to improve the discharge tion, quality measures, and patient surveys References planning process including Project RED with information on readmission rates from 1. Mor V et al. The revolving door of rehospitalization from skilled nursing facilities. Health Aff (Millwood). 2010;29(1):57- (Reengineered Discharge) and Project home health agency services. 64. Dr. Harrington is professor of sociology Boost (Better Outcomes for Older Adults Some states have developed their own 2. Thompson, MP, Waters, TM, Kaplan et al. Most hospitals and nursing; Dr. Ross is a research Through Safe Transitions).4,5 These multi- information on LTC providers. In Cali- received annual penalties for excess readmissions, but some specialist and principal investigator of faceted interventions, both pre- and post- fornia, an integrated single-portal LTC fared better than others. Health Aff (Millwood). 36(5):893-901. the Calqualitycare.org website project; discharge, include institutional self-assess- consumer information website is available 3. Auerbach AD et al. Preventability and causes of readmissions in a national cohort of general medicine patients. JAMA and Dr. Newman is a professor at the ment, team development, stakeholder that includes all licensed LTC providers Intern Med. 2016;176(4):484-93. Institute for Health and Aging, all at the support, and process mapping. Other poli- (about 20,000) including nursing homes, 4. Jack B et al. A reengineered hospital discharge program University of California, San Francisco. cies, practices, and programs have been home health, hospice, residential care, and to decrease rehospitalization: a randomized trial. Ann Intern developed to facilitate transitions after day care (www.Calqualitycare.org). This Med. 2009;150(3):178-87. hospitalization,6-8 but they have not focused model website uses public information 5. Hansen LO et al. Project BOOST: effectiveness of a multi- hospital effort to reduce rehospitalization. J Hosp Med. on the use of currently available post-acute from federal and state sources on deficien- 2013;8(8)421-7. and LTC quality report cards that can cies, complaints, staff and providers, services, 6. Naylor MD et al. The care span: The importance of transi- augment these interventions. quality measures, provider characteristics, tional care in achieving health reform. Health Aff (Millwood). Hospital discharge planning decisions fall and costs. Ratings, similar to the CMS 2011;30(4):746-54. heavily on patients, families, and caregivers, ratings but with more comprehensive state 7. Coleman EA. Family caregivers as partners in care transitions: The caregiver advise record and enable act. J Hosp Med. often with inadequate information about information, are provided. 2016 Dec;11(12):883-5. choices and options. More than 30 states After establishment of the CMS Nursing 8. Leppin AL et al. Preventing 30-day hospital readmissions: have passed the Caregiver Advise, Record, Home Compare rating system in 2008, nurs- a systematic review and meta-analysis of randomized trials. and Enable (CARE) Act into law to require ing homes improved their scores on certain JAMA Internal Med. 2014;174(7):1095-107. 9. Mukamel DB et al. Personalizing nursing home compare hospitals to provide resources for family quality measures and consumer demand and the discharge from hospitals to nursing homes. Health 7 caregiver education and instruction, but significantly increased for the best (five-star) Serv Res. 2016;1(6):2076-94. hospitals do not have to provide informa- facilities and decreased for one-star facili- 10. Werner RM et al. Changes in consumer demand following tion on all LTC options and provider quality ties.10 More recently, a clinical trial of the public reporting of summary quality ratings: An evaluation in ratings. use of a personalized version of Nursing nursing homes. Health Serv Res. 2016;51 Suppl 2:1291-309. 11. Boccuti C et al. Reading the stars: nursing home quality Quality report cards about LTC providers Home Compare in the hospital discharge star ratings, nationally and by state. Kaiser Family Foundation – a major innovation for consumer educa- planning process found greater patient satis- Issue Brief. May 2015. tion and choice – are often not used in the faction, patients being more likely to go to 12. Centers for Medicare & Medicaid Services. Nursing home discharge process for a number of reasons. A higher ranked nursing homes, patients trave- compare data archives. May 2017 monthly files. Quality MSR Claims data. https://data.medicare.gov/data/archives/nurs- significant concern is that using report cards ling further to nursing homes, and patients ing-home-compare. Accessed July 15, 2017. will extend the length of stay. Rather than having shorter hospital stays, compared with 13. Harrington C et al. The need for higher minimum staff- extending the decision-making time and the control group.9 ing standards in U.S. nursing homes. Health Serv Insights. the length of stay, the use of report cards can Quality report cards show wide variations 2016;9:13-9.

16 THE HOSPITALIST I DECEMBER 2017 I www.the-hospitalist.org QUALITY Phoenix Children’s Hospital integrates care from ground up When good care is being given, everyone benefits financially

By Thomas R. Collins the community and recruiting private primary more closely at their cases. from the incentives, that really helps.” care doctors and specialists. Now, more than • A corporate entity created by the hospital Amy Knight, chief operating officer of the bout 4 years ago, officials at Phoenix 1,000 physicians from more than 100 prac- and its community physician partners has a Washington-based Children’s Hospital Asso- AChildren’s Hospital stopped and took tices are part of the network, joined with the doctor-heavy board of directors. ciation, said that, while other children’s hospi- a look around. The adult health care hospital through contracts laden with incen- Some of the care improvements have been tals have migrated toward more integrated care, landscape was zooming toward value-based tives. When good care dramatic, Mr. Johnson said. One teenager had they either haven’t needed to recruit commu- models and integrating care so that previ- is given, the network made 55 ER visits and 21 inpatient visits over nity physicians as they have in Phoenix or ously separate components were now work- gets paid, and everyone 9 months, but the pattern went unnoticed. market conditions have been such that they ing together. The health of whole populations benefits financially. With the new tools the problem became haven’t expanded as quickly. mattered more than ever. “It’s amazing the apparent. A care coordinator found that the “Phoenix saw a huge opportunity and was But their hospital, they found, accounted difference we’re able to mother didn’t understand how to administer very smart about how they approached their for just 9% of the “care touches” – interactions provide when we start the boy’s medication, prompting repeated own market,” she said. “They are definitely on between a patient and a doctor – of their half- linking together what medical crises and hundred of thousands of the front end, the cutting edge of doing that.” million pediatric population. They were not used to be very disparate dollars in unnecessary costs. The teenager has Since its network has expanded, Phoenix working closely with primary care doctors and systems,” Mr. Johnson Mr. Johnson since re-enrolled in school and has had no Children’s has hosted visitors who hope to independent specialists. Patients come to the said. more hospital admissions, Mr. Johnson said. draw lessons from their experience, she said. hospital, they get treated, and then – poof, they Here are some features of the network: He said that, at first, many community “I think what most people go away with is: are gone. The hospital came to a realization • Everyone, including the hospital, is now doctors had a “real skepticism” of being too ‘Very interesting, very cool – not sure it would that there was a better way to provide care. sharing their data. When a child shows up closely tied to a hospital financially, but now work in our market,’” she said. Still, lessons on “We can’t keep doing this alone and saying, at the ED, the ED doctor can quickly see doctors are reaching out to join the network. thinking about risk and building a governance ‘We’re going to impact the overall wellness of things like who the primary care doctor is, “There’s a leap of faith that has to happen in structure are widely applicable, she said. our patients just by being a hospital,’ ” said allergies, medications, and care history. the initial stages,” he said. “When you get the She expects a continued move toward inte- Chad Johnson, senior vice president of Phoe- • Targets such as asthma control, providing insurance companies at the table to really work grated care networks, despite talk about repeal- nix Children’s Care Network. basic wellness exams, and following patients with you to build the right incentives around ing and replacing the Affordable Care Act. They began a process that led to what appropriately, are tied to financial rewards. truly impactful and quality care, you can really “There’s probably some people stepping appears to be a “first-of-its-kind” model, an • Children with complex or special health start to move the needle. When you see – with back in hesitancy, but I don’t think that the integrated care network created from the care needs, and patients who are high utiliz- data – that what you’re doing is having success, political discourse right now will necessarily ground up by a hospital venturing out into ers, have a care coordinator assigned to look and they see the additional money coming change the trajectory that we’re on.”

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www.the-hospitalist.org I DECEMBER 2017 I THE HOSPITALIST 17 Readmissions penalties

CONTINUED FROM PAGE 1 Dr. Frizner Dr. Boutwell Dr. Harrington Dr. Wilborn Dr. Burke relationships with post-acute facilities? The hospitalist’s role incentives for moving patients along and tion between providers – the SNF medical “As of now, the incentives or penalties in post-acute care reducing waste,” Dr. Boutwell said. “For director, the hospitalists, and the emergency haven’t gotten to the level of the individual Hospitalists who work in post-acute care typi- hospitalists practicing in SNFs, it’s going to department.” physician working in long-term care,” said cally make scheduled, billable medical visits be a much bigger phenomenon. They’ll be A TeamHealth doctor in Phoenix has Benjamin Frizner, MD, FHM, director of to patients in long-term care facilities, and called to reevaluate patients and make more convened a consortium of providers from quality and performance for CEP America, may also take on roles such as facility medi- visits than they have been accustomed to.” different care settings to meet and talk about a national provider of emergency, hospital, cal director or contribute to quality improve- She hopes SNFs are studying what happened cases and how they could have gone better. and post-acute medicine. Thus, doctors’ ment. Relationships may be initiated by a with hospitals’ readmission penalties, and “The reality is, these conversations are going professional fees are not affected, he said. facility seeking more medical coverage, by a will respond more quickly and effectively to on all over,” Dr. Wilborn said. “What’s driv- Experts say SNFs – as with hospitals hospitalist group seeking additional work or their own penalty exposure. ing them is the realization of what we all need before them – lack the ability to allocate an ability to impact on the post-acute care Robert Harrington, Jr., MD, SFHM, to do in this new environment.” rewards or penalties for readmission rate delivered to hospital patients discharged to a hospitalist in Alpharetta, Ga., and chief performance to individual doctors. But the facility, or by health systems, health plans, medical officer at Reliant Post-Acute Care Opportunities from reforms increasingly close collaborative relationships or accountable care organizations seeking to Solutions, calls the readmission penalties an Robert Burke, MD, FHM, assistant chief of between post-acute facilities and the hospi- better manage the quality of care transitions extension or further progression of the govern- Hospital Medicine at the Denver VA Medical talists who work in post-acute care mean for their beneficiaries. ment’s value-based purchasing mentality. Center, is lead author of a study in the Journal that the hospitalist has an important role “The facility can ask the hospitalists to “What we are seeing is an effort to shift of Hospital Medicine highlighting implica- in helping the SNF to manage its readmis- come in, or the hospitalist group can ask to folks to lower cost – but still clinically tions and opportunities from reforms in post- sions exposure. come in. You have all of that – plus you’ve appropriate – levels of care,” he said. “These acute care.3 Hospitalists may not appreciate “Hospitals and hospitalists want to keep got big regional and national hospitalist dynamics will force SNFs to reevaluate that post-acute care is poised to undergo good relationships with the SNFs they companies that sign contracts with hospitals and improve their clinical competencies, transformative change from the recently partner with, for a variety of reasons,” Dr. and with large SNFs,” explained Amy Bout- to accept patients and then treat them in legislated reforms, opening opportunities for Frizner said. “We believe that the best way well, MD, MPP, founder of the Massachu- place. It’s no longer acceptable for the medi- hospitalists to improve health care value by to reduce readmissions and unplanned setts-based consulting group Collaborative cal director to make rounds in person twice improving transitions of care, he noted. transfers from the SNF is for the doctor Healthcare Strategies. “It’s clearly becoming a month and do the rest by telephone.” “Most post-acute care placement deci- to know the patient. We need dedicated more common with current market pres- Instead, someone needs to be on site sions are made in the hospital,” Dr. Burke doctors in the facility. We want hospitalists sures,” she said. several times a week, working with nursing said. “As hospitalizations shorten, post- who already know the patient to come to “What I’m seeing is that, with opportuni- staff and developing protocols and pathways acute care utilization is rising, resulting in the facility and see the patient there.” ties for bundled payments, we all have new to control variability, Dr. Harrington said. rapidly increasing costs. Bundled payments “And in many cases that will be a hospital- for care improvement often include a single ist. Hospitalists are finding ways to partner payment for the acute hospital and for post- and provide that level of care. I believe good acute care for up to 90 days postdischarge hospitalist groups can change the facility for for select conditions, which incentivizes the better, and fairly quickly.” hospitalists to reduce hospital length of stay and to choose post-acute alternatives with What happens in post-acute care lower costs,” he said. Cari Levy, MD, PhD, who does hospital “My sense is that payment reform will coverage and post-acute care for a number put pressure on physicians to use home of facilities and home health agencies in the health care more often than institutional Mark your Denver area, calls the changes coming to care, because of the cost pressures. We know SNFs a thrilling time for post-acute care. that hospitalists choose long-term care facil- “Suddenly medical professionals care ity placements less often when participat- about what happens in the post-acute ing in bundled payment,” Dr. Burke said. world,” she said. “Everyone is now looking “I think few hospitalists really know what calendars! at the same measures. If this works the way happens on a day-to-day basis in SNFs – or it should, there would be a lot more mutual in patients’ homes, for that matter.” respect between providers.” According to Dr. Burke, there are just not The 2018 State of Hospital SNFs that are concerned about their read- enough data currently to guide these deci- missions rates will want to do root-cause anal- sions. He said that, based on his research, Medicine Survey opens on ysis to figure out what’s going on, Dr. Levy the best thing hospitalists can do is try to said. “Maybe the doctor didn’t do a good understand what’s available in post-acute January 8, 2018. assessment. Maybe it was just a tough case. spaces, and build relationships with post- Once you start talking, you’ll develop systems acute facilities. to help everyone responsible. Hospitalists can “Find ways to get feedback on your be part of that conversation,” she said. discharge decisions,” he said. “Here in Colo- Jerome Wilborn, MD, national medical rado, we met recently with the local chapter Your participation is extremely important director of post-acute care for TeamHealth, of the Society for Post-Acute and Long-Term in creating the most up-to-date snapshot Knoxville, Tenn., says his company is one Care Medicine, also known as AMDA. It’s of the largest groups tackling these issues. been revealing for everyone involved.” of the state of hospital medicine. “And we’re aligning around these precepts He recommends AMDA’s learning modules very quickly. If I’m a hospital administrator, – which are designed for doctors who are new I’m already under the gun with readmissions to long-term care – to any hospitalist who is penalties and with Press Ganey patient satis- entering the post-acute world. faction scores weighing heavily on me. Medi- care will be paying more based on value, not References volume, so our income will be more depend- 1. Mor V et al. The revolving door of rehospitalization from ent on our outcomes,” Dr. Wilborn said. skilled nursing facilities. Health Aff (Millwood). 2010 Jan- “You can have a good outcome at Shady Feb;29(1):57-64. Oaks and a terrible outcome at Whispering 2. Brennan N et al. Data Brief: Sharp reduction in avoidable hospitalizations among long-term care facility residents. The hospitalmedicine.org Pines, for all sorts of reasons. The hospital CMS Blog, 2017 Jan 17. wants to make sure we’re sending patients to 3. Burke RE et al. Post-acute care reform: Implications facilities that produce good outcomes,” he and opportunities for hospitalists. J Hosp Med. 2017 explained. “But there has to be communica- Jan;12(1):46-51.

18 THE HOSPITALIST I DECEMBER 2017 I www.the-hospitalist.org PRACTICE MANAGEMENT Readmission rates linked to hospital quality measures Experts say readmission measure classifies true differences in performance

BY Alicia Gallegos Frontline Medical News

oorer-performing hospitals have higher readmission rates Pthan better-performing hospitals for patients with similar diagnoses, a study shows. Lead author Harlan M. Krumholz, MD, of Yale University, New Haven, Conn., and his colleagues analyzed Centers for Medicare & Medicaid Services hospital-wide readmission data and divided data from July 2014 through June 2015 into two random samples. Researchers used the first sample to calcu- late the risk-standardized readmission rate within 30 days for each hospital and classified hospitals into performance quartiles, with a lower readmission rate indicating better performance. The second study sample included patients who had two admissions for similar diagnoses at different hospitals that occurred more than 1 month and less than 1 year apart. Researchers compared the observed readmission rates among patients who had been admitted to hospitals in different performance quartiles. The analysis included all discharges occurring from July 1, 2014, through June 30, 2015, from short-term those admitted to the best-performing quartile (absolute differ- tals, this study was able to isolate hospital signals of perfor- acute care or critical access hospitals in the United States involv- ence in readmission rate, 2.0 percentage points; 95% confi- mance while minimizing differences among the patients. In ing Medicare patients who were aged 65 years or older. dence interval, 0.4-3.5; P = .001) (N Engl J Med. 2017. doi: these cases, because the same patients had similar admissions In the period studied, there were a total of 7,163,152 hospi- 10.1056/NEJMsa1702321). The differences in the compari- at two hospitals, the characteristics of the patients, including talizations, of which 6,910,341 met the inclusion criteria for sons of the other quartiles were smaller and not significant, their level of social disadvantage, level of education, or degree the hospital-wide risk-standardized readmission measure. according to the study. of underlying illness, were broadly the same. The alignment of Of these hospitalizations, 3,455,171 discharges (involv- The findings suggest that hospital quality contributes at least the differences that we observed with the results of the CMS ing 2,741,289 patients and 4,738 hospitals) were randomly in part to readmission rates, independent of patient factors, hospital-wide readmission measure also adds to evidence that selected for the first sample for calculation of hospital-read- study authors concluded. the readmission measure classifies true differences in perfor- mission performance. The second sample included 3,455,170 “This study addresses a persistent concern that national mance.” Dr. Krumholz and seven coauthors reported receiv- discharges, 132,283 of which involved patients who had two readmission measures may reflect differences in unmeasured ing support from contracts with the Center for Medicare & or more admissions for similar diagnoses at least 30 days apart. factors rather than in hospital performance,” study authors Medicaid Services to develop and reevaluate performance Results found that among the patients hospitalized more noted in the study. “The findings suggest that hospital quality measures that are used for public reporting. than once for similar diagnoses at different hospitals, the read- contributes at least in part to readmission rates, independent mission rate was significantly higher among patients admit- of patient factors. With use of patients who were admitted [email protected] ted to the worst-performing quartile of hospitals than among twice within 1 year with similar diagnoses to different hospi- On Twitter @legal_med Readmission risk: Isolating hospital effects from patient effects The Hospital Readmission Reduc- low-income Medicare patients have greater challenges in reducing reading high-risk social conditions driving tion Program (HRRP) was established not had as significant reduction in missions. It is difficult to determine readmissions, intensive discharge in 2011 by a provision in the Afford- readmissions as their counterparts.2 which socioeconomic factors play planning, and deploying community able Care Act (ACA) requiring Medi- One of the biggest complaints leveled the biggest role in driving readmission health care workers. A key compo- care to reduce payments to hospitals at the HRRP program is that it is indif- rates and even more difficult to change nent of this has been addressing the with relatively high readmission rates ferent to the socioeconomic circum- them. This study also demonstrates opioid epidemic. for patients in traditional Medicare. stances of a hospital’s patient popula- that despite challenging conditions, Despite some opposition, the Since the inception. In many of these hospitals, efforts reductions in readmissions can occur. HHRP has worked by aligning finan- tion of the HRRP, to reduce readmissions have been As the primary focus and leader cial incentives with good health care. readmission rates seen as futile exercises in a patient of health care in most communities, The program was successful not by have declined population with complex social needs. hospitals are best equipped to reach developing complicated metrics, but across all meas- A study published in the journal into the community and to develop rather by simply providing finan- ured diagnostic Health Affairs found that socioeco- successful transition programs that cial incentives for good care and categories result- nomic factors do appear to drive many limit readmissions and begin to then allowing innovation to develop ing in estimates of the difference in readmission rates address complex social needs. Of independently. Hopefully this study of 565,000 fewer between safety net hospitals and their course this must be a coordinated further promotes these efforts. Medicare read- Dr. Krumholz more prosperous peers. However, it effort among many groups, but the missions through also suggested that hospital perfor- hospital and its organization is in the Kevin Conrad, MD, is medical director of 2015.1 These reductions seem to be mance may play a factor as well.3 right position to take a leading role. It community affairs and healthy policy at driven by penalties demonstrated by The NEJM article, Hospital-Read- is essential that hospitalists, who are Ochsner Health System, New Orleans. the fact that readmissions fell more mission Risk – Isolating Hospital on the front lines of this process, play quickly at hospitals that had readmis- Effects from Patient Effects confirms a significant role. References sion penalties than at other hospitals. this. This well-designed review deter- Many hospitals with patients who 1. Zuckerman RB et al. Readmissions, observation, and the Although the severity and fairness mined that hospitals, independent have complex needs are rising to the hospital readmissions reduction program. N Engl J Med. 2016 April 21;374:1543-1551. of the penalties can be debated, the of a patient’s socioeconomic status, occasion. Motivated by the HRRP, 2. Jencks SF et al. Hospitalizations among patients in HRRP has been successful in achiev- had an impact on the likelihood of unique innovations to improve care the Medicare Fee-for-Service Program. N Engl J Med. ing the goal of reducing readmissions. patient being readmitted. The more transitions out of hospitals are being 2009.360(14):1418-1428; Epstein AM et al. The relation- Despite these declines seen in most complicated question of what higher developed. Hospitals that are serving ship between hospital admission rates and rehospitaliza- tions. N Engl J Med. 2011. 365(24):2287-2295. hospitals, readmission rates have not functioning hospitals did to reduce low socioeconomic populations are 3. Kahn C et al. Assessing Medicare’s hospital Pay-for- declined among all hospitals. Hospi- readmissions was not addressed. It is finding innovative ways to reduce Performance programs and whether they are achieving tals that have higher proportions of certain that some hospitals will face readmissions. These include identify- their goals. Health Affairs. 2015 Aug;34(8).

www.the-hospitalist.org I DECEMBER 2017 I THE HOSPITALIST 19 NEWS I Clinical developments and health care policy, regulations BP accuracy is the ghost in the machine

BY M. Alexander Otto matters more than the first; and that most Frontline Medical News Americans need a large-sized cuff. Current “Most of the time, the patient walks over guidelines are based on patients sitting for EXPERT ANALYSIS FROM JOINT 5-10 minutes alone in a quiet room while an HYPERTENSION 2017 from the waiting room, they get on the automatic machine averages their last three to SAN FRANCISCO – Amid all the talk about five blood pressures. scale which automatically elevates the subgroup blood pressure targets and tiny But when Dr. Yarows asked his 300 or so differences in drug regimens at a recent hyper- audience members – hypertension physicians blood pressure tremendously, and then tension meeting, there was an elephant in the who paid to come to the meeting – how many room that attendees refused to ignore. actually followed those rules, four hands went they sit down and talk about their family Hypertension control – the No. 1 way to up. It’s not good enough; “if you are going to prevent cardiovascular death – depends on make a diagnosis that lasts a lifetime, you have while their blood pressure is being taken.” a simple measurement taught to all medical to be accurate,” he said at the joint scientific – Steven Yarows, MD practitioners, but one that’s rarely done right: sessions of the American Heart Association blood pressure measurement. When it comes Council on Hypertension, AHA Council on to the one thing that matters most, “we do it Kidney Cardiovascular Disease, and American from the waiting room, they get on the scale Another patient was 114/85 mm Hg at noon, wrong,” said Steven Yarows, MD, a primary Society of Hypertension. which automatically elevates the blood pres- and 159/73 mm Hg an hour later. “That’s a care physician in Chelsea, Mich., who esti- There’s resistance. No one has a room set sure tremendously, and then they sit down huge spread,” he said. mated he’s taken 44,000 blood pressures in aside for blood pressure; staff don’t want to and talk about their family while their blood Twenty-four hour monitoring is the only his 36 years of practice. deal with it; and at a time when primary care pressure is being taken.” Even in normotensive way to really know if patients are hypertensive Inaccurate measurement is such a prob- doctors are nickel and dimed for everything patients, that alone could raise systolic pressure and need treatment. “Any person you suspect lem in the United States that someone in his they do, insurers haven’t stepped up to pay to 20 mm Hg or more, he said. It makes one-time of having hypertension, before you place them audience half-joked that the American Heart make accurate blood pressure a priority. blood pressure pretty much meaningless. on medicine, you should have 24 hour blood Association should release two hypertension To do it right, you have to ask patients to The biggest problem is that blood pressure pressure monitoring. This is the most effec- guidelines the next time around, one for when come in 10 minutes early and have a room set is hugely variable, so it’s hard to know what tive way to determine if they do have high blood pressure is measured correctly, “and one up for them where they can sit alone with a matters. In one of Dr. Yarows’ normotensive blood pressure,” and how much it needs to be for the rest of us.” large oscillometric cuff to average a few blood patients, BP varied 44 mm Hg systolic and 37 lowered, he said. Everyone in medicine is taught that people pressures at rest, Dr. Yarows said. They also mm Hg diastolic over 24 hours. In a hyper- Dr. Yarows had no disclosures. should rest a bit and not talk while their blood need at least one 24-hour monitoring. tensive patient, systolic pressure varied 62 mm pressure is taken; that the last measurement “Most of the time, the patient walks over Hg and diastolic 48 mm Hg over 24 hours. [email protected]

24 THE HOSPITALIST I DECEMBER 2017 I www.the-hospitalist.org Mental Health Care

CONTINUED FROM PAGE 1

ably the top manpower shortage among all tute or in behavioral health service, more specialties,” said Joe Parks, MD, medical likely than not, you’re going to invest it in “If we can’t reimburse people fairly for director of the National Council for Behav- the more profitable cardiovascular service ioral Health. “We have about a third the line.” doing really important work, we’re not number of psychiatrists that most estimates say we need, and the number per capita is Providers of last resort going to drive up the demand for more decreasing.” A significant percentage of But much of the burden of caring for this psychiatrists – more than 50% – accept only population ends up falling on hospitals people to think about how to better cash, bypassing the low reimbursement rates by default. At Denver Health, Melanie even private insurance typically offers. Rylander, MD, medical director of the serve people from a mental health This is all evidence of our broad unwill- inpatient psychiatric unit, reports seeing ingness, as a society, to invest in mental this manifest in three categories of patients. perspective.” health, said Teresa Nguyen, LCSW, vice First, there is an influx of people coming –Teresa Nguyen, LCSW, vice president of policy and programs president of policy and programs at Mental into the emergency department with at Mental Health America Health America. “If we can’t reimburse primary mental health issues. people fairly for doing really important “We’re also seeing an influx of people work, we’re not going to drive up the coming in with physical problems, and demand for more people to think about upon assessment it becomes very clear very an internist’s training to be familiar with a its way into the hospital setting in various how to better serve people from a mental quickly that the real issue is an underlying lot of the medications,” said Atashi Mandal, ways. In their efforts to bring the care to the health perspective.” mental health issue,” she said. Then there MD, a hospitalist and pediatrician in Los patient, rather than the other way around, Hospitals, of course, feel those finan- are the people coming in for the same physi- Angeles. “Sometimes they get improperly Dr. Karlin-Zysman’s hospital embedded cial disincentives too, which discourage cal problems over and over – maybe decom- medicated because we don’t know what else two hospitalists in the neighboring inpa- them from investments of their own. “It’s pensated heart failure or chronic obstructive to do and the patient’s behavioral issues are tient psychiatric hospital; when patients a difficult population to manage, and it’s pulmonary disease exacerbations – because escalating, so it’s really a difficult position.” need medical treatment, they can receive it difficult to manage the financial realities of mental health issues are impeding their abil- It’s a dispiriting experience for a hospital- without interrupting their behavioral health mental health as well,” said John McHugh, ity to take care of themselves. ist. “It really bothers me when I am trying to treatment. As a result, patients who used to PhD, assistant professor of health policy at Some hospitalists say they feel ill equipped care for a patient who has psychiatric needs, end up in their emergency department don’t Columbia University, New York. “If you to care for these patients. “We don’t have the and I feel I’m not able to do it, and I can’t anymore, and their 30-day readmission rate were a hospital administrator looking to facility or the resources many times to prop- find resources, and I feel that this patient’s has fallen by 50%. invest your last dollar and you have the erly care for their psychiatric needs when needs are being neglected – not because But at its foundation, care integration is option of investing it in a new heart insti- they’re in the hospital. It’s not really part of we don’t care, and not because of a lack of more of an attitude than a system; it begins effort by the staff. It’s just set up to fail,” Dr. with a mindset. Mandal said. “We talk so much today about system reform, integrated systems, blah, blah,” Ending the silo mentality said Lisa Rosenbaum, MD, a cardiologist Encouraging a more holistic view of health at Brigham and Women’s Hospital, Boston. across health care would be an important “I don’t want to make it seem like it’s not step to begin to address the problem – after going to work, but what does it mean for the all, the mind and the body are not separate. patient who is psychotic and has 10 prob- “We work in silos, and we really have lems, with whom you have 15 minutes? to stop doing that because these are inter- Taking good care of these patients means twined,” said Corey Karlin-Zysman, MD, you have to take a deep breath and put in a FHM, FACP, chief of the division of lot of time and deal with all these things that hospital medicine at Northwell Health. have nothing to do with the health system “A schizophrenic will become worse when under which you practice. There’s this ‘only they’re medically ill. That illness will be so much you can do’ feeling that is a prob- harder to treat if their psychiatric illness lem in itself, because there’s actually a lot is active.” This is starting to happen in we can do.” the outpatient setting, evidenced by the expansion of the integrated care model, Hospitals and communities “We’re also seeing an influx where a primary care doctor is the lead It’s axiomatic to say that a better approach physician working in combination with to mental health would be based around of people coming in with psychologists, psychiatrists, and social prevention and early intervention, rather workers. Communication among provid- than the less crisis-oriented system we have physical problems, and upon ers becomes simpler, and patients don’t fall now. Some efforts are being made in that through the cracks as often while trying to direction, and they involve, and require, assessment it becomes very navigate the system. outreach outside the hospital. “How do we promote even more of “The best hospitals doing work in clear very quickly that the that? If we make things easier for patients mental health are going beyond the hospi- real issue is an underlying and increase the odds of compliance, then tal walls; they’re really looking at their maybe they won’t need to go to the hospi- community,” Dr. Nguyen said. “You have mental health issue.” tal,” Dr. Karlin-Zysman said. “Patients hospitals, like Accountable Care Organiza- with behavioral health issues are just not tions, who are trying to move earlier and getting the level of care and attention they think about mental health from a pediatric need, and we have to figure it out. They’re standpoint: How can we support parents going to be a bigger and bigger proportion and children during critical phases of brain of patients that we’re going to see in the growth? How can we provide prevention hospital setting, but it doesn’t have to be services?” Ultimately, those efforts should dealt with in the hospital setting if it’s better help lower future admission rates to EDs treated in the outpatient setting.” and hospitals. That idea of integration is also making CONTINUED ON FOLLOWING PAGE

www.the-hospitalist.org I DECEMBER 2017 I THE HOSPITALIST 25 CONTINUED FROM PREVIOUS PAGE

That forward-looking approach may problems, they need to be part of the discus- be necessary, but it’s also a challenge. “As sions taking place in communities among a hospital administrator, I would think the various systems and providers and advo- “We work in silos, and we really have that you look out at the community and cates,” Mr. Honberg said. “Ultimately, we to stop doing that because these see this problem is not going away – in need to develop a better community-based fact, it is likely going to get worse,” Dr. system of care, and a better way of hand- are intertwined. A schizophrenic will McHugh said. “A health system may look ing people off from inpatient to commu- at themselves and say we have to take the nity-based treatment, and some account- become worse when they’re medically lead on this.” The difficulty is that think- ability in terms of requiring that people get ing of it in a sense of value to the commu- services, so they don’t get rehospitalized ill. That illness will be harder to treat if nity, and making the requisite investments, quickly. You’re increasingly seeing account- will have a very long period of payout; a ability now with other health conditions; their psychiatric illness is active.” health system that’s struggling may not be we’re measuring things in Medicare like –Corey Karlin-Zysman, MD, FHM, FACP, chief of the division able to do it. “It’s the large [health systems] rehospitalization rates and the like. We need that tend to be more integrated … that to be doing that with mental health treat- of hospital medicine at Northwell Health are thinking about this much differently,” ment as well.” he said. Still, the reality is that’s where the root What a hospitalist can do As this challenge seems likely to continue not be uncommon for us to have some - of the problem lies, Dr. Rylander said One thing hospitalists might consider is to grow, hospitalists might consider find- times close to 30 patients who needed – not in the hospital, but in the larger starting that practice at their own hospi- ing more training in mental health issues 24-hour continuous observation to community. “In the absence of very basic tals, measuring, recording, and sharing that themselves so they are more comfortable make sure they were not hurting them - needs – stable housing, food, heating – it’s kind of information. handling these issues, Dr. Parks said. “The selves.” These PCAs or nurse’s assistants really not reasonable to expect that people “Hospitalists should measure system- average mini-psych rotation from medi- were doing 8-hour shifts, so each patient are going to take care of their physical atically, and in a very neutral manner, the cal school is only 4 weeks,” he noted. “The needed three. “The math is staggering – needs,” she said. “It’s a much larger social total burden and frequency of the problem ob.gyn. is at least 8 weeks and often 12 and with not any better outcomes.” issue: how to get resources so that these and report it consistently to management, weeks, and if you don’t go into ob.gyn., So the hospital created a 15-bed closed people can have stable places to live, they along with their assessment that this impairs you’re going to see a lot more mentally ill med-psych unit for medically ill patients can get to and from appointments, that the quality of care and creates patient risk,” people through the rest of your practice, no with behavioral health disorders. They type of thing.” Dr. Parks said. That information can help matter what you do, than you are going to staffed it with a dedicated hospitalist, a Those needs are ongoing, of course. hospitalists lobby for access to psychiatric see pregnant women.” nurse practitioner, a psychologist, and a Many of these patients suffer from chronic personnel, be that in person or through tele- Just starting these conversations – with nurse manager. conditions, meaning people will continue medicine. “We don’t have to lay hands on patients, with colleagues, with family and The number of patients requiring contin- to need services and support, said Ron you. There’s no excuse for any hospital not friends – might be the most important uous observation fell to single digits. Once Honberg, JD, senior policy adviser for the having a contract in place for on-demand change of all. “Even though nobody is above in their own unit, these patients caused less National Alliance on Mental Illness. Often, consultation in the ER and on the floors.” these issues afflicting them, this is still some- disruption and stress on the medical units. people need services from different systems. Track outcomes, too, Dr. Mandal thing that is not part of an open dialogue, They had a lower length of stay compared “There are complexities in terms of navigat- suggests. With access to the right person- and this is something that affects our own to their previous admissions in other units, ing those systems and getting those systems nel, are you getting patients out of the colleagues,” Dr. Mandal said. “I don’t know and this became one of the hospital’s highest to work well together. Until we make ED faster? Are you having fewer negative how many more trainees jumping out of performing units in terms of patient expe- inroads in solving those things, or at least outcomes while these patients are in the windows it will take, or colleagues going rience. improving those things, the burdens are hospital, such as having to use restraints or through depression and feeling that it’s a The biggest secret of their success, Dr. going to fall on the providers of last resort, get security involved? “Hopefully you can sign of weakness to even talk about it. Karlin-Zysman said, is cohorting. “Instead and that includes hospitals,” he said. get some data in terms of how much money “We need to create safe harbors within of them going to the next open bed, wher- A collaborative effort may be needed, but you’ve saved by decreasing the length of our own medical communities and ever it may be, you get the patients all in one hospitals can still be active participants and stays and decreasing inadvertent adverse acknowledge that we ourselves can be prone place geographically, with a team trained to even leaders. effects because the patients weren’t receiv- to this,” he said. “Perhaps by doing that, manage those patients.” Another factor: It’s “If hospitals really want to address these ing the proper care,” he said. we will develop more empathy and become a hospitalist-run unit. “You can’t have 20 more comfortable, not just with ourselves different doctors taking care of the patients; and our colleagues but also helping these it’s one or two hospitalists running this unit.” “It’s a difficult population to manage, patients. People get overwhelmed and Care models like this can be a true win- throw their hands up because it is just such win, and her hospital is using them more and it’s difficult to manage the financial a difficult issue. I don’t want people to give and more. up, both from the medical community and “I have a care model that’s a stroke unit; realities of mental health as well. If you our society as a whole – we can’t give up.” I have a care model that’s an onc unit and one that’s a pulmonary unit,” she said. were a hospital administrator looking A med-psych unit pilot project “We’re creating these true teams, which I Med-psych units can be a good model to think hospitalists really like being part of. to invest your last dollar and you have take on these challenges. At Long Island What’s that thing that makes them want to the option of investing it in a new Jewish Medical Center, they launched a come to work every day? Things like this: pilot project to see how one would work running a care model, becoming special- heart institute or in behavioral health in their community and summarized the ized in something.” There are research and results in an SHM abstract. abstract opportunities for hospitalists on service, more likely than not, you’re The hospital shares a campus with a these units too, which also helps keep them 200-bed inpatient psych hospital, and engaged, she said. “I’ve used this care model going to invest it in the more profitable doctors were seeing a lot of back and and things like that to reduce burnout and forth between the two institutions, said keep people excited.” cardiovascular service line.” Dr. Karlin-Zysman. “Patients would –John McHugh, PhD, assistant professor of health policy at come into the hospital because they had The persistent mortality gap an active medical issue, but because of Patients with mental illness tend to receive Columbia University, New York their behavioral issues, they’d have to worse medical care than people without, have continuous observation. It would studies have shown; they die an average of

26 THE HOSPITALIST I DECEMBER 2017 I www.the-hospitalist.org “There are complexities in terms of navigating those systems and getting those systems to work well together. Until we make inroads in solving those things, or at least improving those things, the burdens are going to fall on 25 years earlier, largely from preventable or These hurdles may foster a sense of help- treatable conditions such as cardiovascular lessness among hospitalists who have just the providers of last resort, and that disease and diabetes. The World Health a small amount of time to spend with a Organization has called the problem “a patient, and attitudes may be hard to change. includes hospitals.” hidden human rights emergency.” “Negotiating more effectively about care In one in a series of articles on mental refusals, more adeptly assessing capacity, –Ron Honberg, JD, senior policy adviser for the National health, Dr. Rosenbaum: Might physician and recognizing when our efforts to orches- Alliance on Mental Illness attitudes toward mentally ill people contrib- trate care have been inadequate seem feasi- ute to this mortality gap, and if so, can we ble,” Dr. Rosenbaum writes. “Far harder change them? is overcoming any collective belief that She recognizes the many obstacles physi- what mentally ill people truly need is not on Mental Illness addresses mental illness 2. Mental Health America. The State of Mental Health in America. http://www.mentalhealthamerica.net/issues/ cians face in treating these patients. “The something we can offer.” That’s why a truly issues from a provider perspective. state-mental-health-america. Accessed March 30, 2017. medicines we have are good but not great honest examination of attitudes and biases “Although the description states that 3. Karlin-Zysman C, Lerner K, Warner-Cohen J. Creating a and can cause obesity and diabetes, which is a necessary place to start. the course is intended for mental health Hybrid Medicine and Psychiatric Unit to Manage Medically contributes to cardiovascular morbidity and She tells the story of one mentally ill professionals, it can be and has been used to Ill Patients with Behavioral Health Disorders [abstract]. Journal of Hospital Medicine. 2015; 10 (suppl 2). http:// mortality,” Dr. Rosenbaum said. “We have patient she learned of in her research, who, educate and inform other healthcare profes- www.shmabstracts.com/abstract/creating-a-hybrid- the adherence challenge for the psychiat- after decades as the quintessential frequent sionals as well,” said Mr. Honberg. The medicine-and-psychiatric-unit-to-manage-medically- ric medications and for medications for flier in the ER, was living stably in the standard course takes 15 hours; there is an ill-patients-with-behavioral-health-disorders/. Accessed March 19, 2017. chronic disease. It’s hard enough for anyone community. “No one could have known abbreviated 4-hour alternative as well. More 4. Garey J. When Doctors Discriminate. New York Times. to take a medicine every day, and to do that how many tries it would take to help him information can be found at http://www. http://www.nytimes.com/2013/08/11/opinion/sunday/ if you’re homeless or you don’t have insight get there,” she writes. His doctor told her, nami.org/Find-Support/NAMI-Programs/ when-doctors-discriminate.html. August 10, 2013. into the need for it, it’s really hard.” “Let’s say 10 attempts are necessary. Some- NAMI-Provider-Education. Accessed March 15, 2017. Also, certain behaviors that are more one needs to be number 2, 3 and 7. You just 5. Rosenbaum L. Closing the mortality gap – mental illness common among people with serious mental never know which number you are.” Sources and medical care. N Engl J Med. 2016; 375:1585-1589. doi: 1. Szabo L. Cost of Not Caring: Nowhere to Go. USA Today. 10.1056/NEJMms1610125. illness – smoking, substance abuse, physical https://www.usatoday.com/story/news/nation/2014/05/12/ 6. Rosenbaum L. Unlearning Our Helplessness – Coex- inactivity – increase their risk for chronic Education for physicians mental-health-system-crisis/7746535/. Accessed March isting Serious Mental and Medical Illness. N Engl J Med. diseases. A course created by the National Alliance 10, 2017. 2016;375:1690-4. doi: 10.1056/NEJMms1610127. YOU BELONG HERE Find your place in the hospital medicine movement at HM18

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www.the-hospitalist.org I DECEMBER 2017 I THE HOSPITALIST 27 CLINICAL

KEY CLINICAL QUESTION When should I transfuse a patient who has anemia? Weighing the potential adverse effects, cost of transfusions

By Hemal N. Sampat, MD; Rebecca Berger, MD; and Farrin A. Manian, MD, MPH Massachusetts General Hospital, Boston

KEY POINTS

• The AABB guidelines recommend transfusing stable The case general medical inpatients to a hemoglobin level of 7 g/dL. A 48-year-old man with cirrhosis and esophageal varices presents • For patients undergoing to the emergency department with orthopedic surgery or cardiac hematochezia and hematemesis. surgery, and those with preex- Upon arrival to the floor, he has isting cardiovascular disease, a another bout of hematochezia and transfusion threshold of 8 g/dL hematemesis. He appears pale. is recommended. His pulse is 90 beats per minute, his blood pressure is 100/60 mm • Patients with hemodynamic Hg, and his respiratory rate is 14 instability or active blood loss breaths per minute. A complete should be transfused based on blood count reveals a hemoglobin clinical criteria, and not abso- level of 7.8 g/dL and hematocrit of lute hemoglobin levels. 23.5%. Should he receive a blood transfusion? • Patients with acute coronary syndrome, severe thrombocytopenia, and chronic transfusion–dependent anemia are Introduction focused on the evidence for hemodynami- ments in Septic Shock (TRISS) study excluded from these recom- Anemia is one of the most frequent condi- cally stable and asymptomatic hospital- involved patients with septic shock and simi- mendations. tions in hospitalized patients. Anemia is ized patients. The guidelines are based on larly found that patients assigned to a restric- variably associated with morbidity and randomized, controlled trials that meas- tive strategy (transfusion for hemoglobin • Further studies are needed mortality depending on chronicity, etiol- ured mortality as the primary endpoint. less than 7 g/dL) had similar outcomes to to further refine these recom- ogy, and associated comorbidities. Before Most trials and guidelines reinforce that, if patients assigned to a liberal strategy (transfu- mendations to specific patient the 1980s, standard practice was to trans- a patient is symptomatic or hemodynami- sion for hemoglobin less than 9 g/dL). The populations in maximizing the fuse all patients to a hemoglobin level cally unstable from anemia or hemorrhage, patients in the restrictive group received benefits and minimizing the greater than 10 g/dL and/or a hematocrit RBC transfusion is appropriate irrespective fewer transfusions, but had similar rates of risks of blood transfusions. greater than 30%. However, with concerns of hemoglobin level. 90-day mortality, use of life support, and about the potential adverse effects and cost number of days alive and out of the hospital.4 of transfusions, the safety and effective- Overview of the data These large randomized, controlled trials ness of liberal versus restrictive transfusion in critically ill patients served as the basis for thresholds became the subject of many Critically ill patients subsequent studies in patient populations studies. The Transfusion Requirements in Critical outside of the ICU. Risks of red blood cell transfusions Care (TRICC) trial, published in 1999, include transmission of bloodborne patho- was the first large clinical trial examining Acute upper GI bleed gens and, more commonly, immunological the safety of restrictive transfusion thresh- Acute upper gastrointestinal bleeding reactions and other noninfectious complica- olds in critically ill patients.3 (UGIB) is one of the most common indi- tions. Modern screening methods for HIV, The TRICC trial randomized 838 cations for RBC transfusion. hepatitis B, and hepatitis C infections in euvolemic critically ill patients with anemia A 2013 single-center study randomized developed countries have markedly reduced to a restrictive transfusion strategy (transfus- patients with and without cirrhosis who the incidence of transfusion-related diseases ing for hemoglobin less than 7 g/dL) or a presented with evidence of UGIB, such as due to these pathogens, such that in the liberal strategy (transfusing for hemoglobin hematemesis, melena, or bloody nasogas- United States the risk of transfusion-related less than 10 g/dL). Thirty-day mortality was tric aspirate, to either a restrictive or liberal HIV, hepatitis B, or hepatitis C infections is not significantly different between the two transfusion strategy, with hemoglobin trans- extremely rare (nearly 1 in a million units or groups, though in prespecified subgroups of fusion thresholds of less than 7 g/dL and less).1,2 In contrast, noninfectious compli- less acutely ill patients (APACHE-II score less than 9 g/dL, respectively. All patients cations such as febrile transfusion reac- 20 or lower) and younger patients (age less received 1 unit of RBCs before assessing tions, transfusion-associated circulatory than 55 years), mortality was significantly baseline hemoglobin level, and all patients overload, and allergic reactions are much lower in the restrictive transfusion group. underwent upper endoscopy within 6 more common.1 Overall in-hospital mortality was also lower hours. Patients in the restrictive-strategy The 2016 AABB (formerly American in the restrictive strategy arm. group had significantly lower mortality at Association of Blood Banks) guidelines The subsequent Transfusion Require- CONTINUED ON PAGE 33

28 THE HOSPITALIST I DECEMBER 2017 I www.the-hospitalist.org KEY CINICAL QUESITON I continued from page 28

45 days, compared with the liberal-strategy group. This finding persisted in a subgroup QUIZ of patients with Childs-Pugh class A or B cirrhosis, but not Childs-Pugh class C.5 In which of the following scenarios is RBC transfusion LEAST indicated? The TRIGGER trial, a cluster randomized multicenter study published in A. Active diverticular bleed, heart rate 125 beats/minute, blood pressure 2015, also found no difference in clinical 85/65 mm HG, hemoglobin 10.5 g/dL outcomes, including mortality, between a restrictive strategy and liberal strategy for B. Septic shock in the ICU, hemoglobin 6.7 g/dL transfusion of patients with UGIB.6 C. Pulmonary embolism in the setting of stable coronary artery disease Perioperative patients and hemoglobin 8.7 g/dL Transfusion thresholds have been studied in large randomized trials for perioperative D. Lymphoma on chemotherapy, hemoglobin 7.5 g/dL, patient becomes patients undergoing cardiac and orthope- dizzy when standing dic surgery. The Transfusion Requirements After Answer: C – A hemoglobin transfusion goal of 8.0 g/dL is recommended Cardiac Surgery (TRACS) trial, published for patients with cardiovascular disease. The patient in answer choice in 2010, randomized patients undergoing A has active blood loss, tachycardia, and hypotension, all pointing to cardiac surgery at a single center to a liberal the need for blood transfusion irrespective of an initial hemoglobin level strategy of blood transfusion (to maintain greater than 8.0 g/dL. The patient in answer choice B has a hemoglobin a hematocrit 30% or greater) or a restric- level greater than 7.0 g/dL, and the patient in choice D is symptomatic, tive strategy (hematocrit 24% or greater).7 possibly from anemia, as well as on chemotherapy, therefore making Mortality and severe morbidity rates were transfusion a reasonable option. noninferior in the restrictive strategy group. Mean hemoglobin concentrations were 10.5 g/dL in the liberal-strategy group and 9.1 g/dL in the restrictive-strategy group. Independent of transfusion strategy, the Most trials and guidelines reinforce that, if a patient is number of transfused red blood cell units symptomatic or hemodynamically unstable from anemia was an independent risk factor for clinical complications and death at 30 days. or hemorrhage, RBC transfusion is appropriate irrespec- Subsequently, the Functional Outcomes in Cardiovascular Patients Undergoing tive of hemoglobin level. Surgical Hip Fracture Repair (FOCUS) study enrolled patients aged 50 years and older with cardiovascular disease or coronary artery disease risk factors undergoing In a subgroup analysis of patients with his active bleeding; his hemoglobin level hip surgery randomized to either a liberal “cardiovascular disease” the FOCUS trial should not be a determining factor under transfusion strategy (goal hemoglobin found no difference in outcomes between such circumstances. This distinction is one Dr. Sampat, Dr. Berger, and Dr. Manian 10 g/dL or greater) or restrictive strategy a restrictive and liberal transfusion strat- of the most fundamental in interpreting are hospitalists at Massachusetts (goal hemoglobin 8 g/dL or greater) was egy, although there was a marginally the guidelines; that is, patients with hemo- General Hospital, Boston. performed.8 This study found no differ- higher incidence of myocardial infarction dynamic insult, symptoms, and/or ongo- ence in outcomes between the two groups, in the restrictive arm in the entire study ing bleeding should be evaluated clinically, including mortality, inability to walk, or population.8 independent of their hemoglobin level. in-hospital complications. Although some studies have included Based on these two trials, as well as other patients with congestive heart failure Bottom line smaller randomized controlled trials and (CHF) as a subgroup, these subgroups are Although recent guidelines generally favor observational studies, the AABB guidelines often not powered to show clinically mean- a more restrictive hemoglobin goal thresh- recommend a restrictive RBC transfusion ingful differences. The risk of volume over- old, in the presence of active blood loss or threshold of 8 g/dL for patients undergoing load is one explanation for why transfusions hemodynamic instability, blood transfu- cardiac or orthopedic surgery.1 may be harmful for patients with CHF. sion should be considered independent of Based on these limited available data, the the initial hemoglobin level. Acute coronary syndrome, stable coro- AABB guidelines recommend a “restrictive nary artery disease, and congestive heart RBC transfusion threshold (hemoglobin References failure level of 8 g/dL)” for patients “with preexist- 1. Carson JL et al. Clinical Practice Guidelines From the AABB: Red Blood Cell Transfusion Thresholds and Storage. Anemia is an independent predictor of ing cardiovascular disease,” without distin- JAMA. 2016;316:2025-35. major adverse cardiovascular events in guishing among patients with acute coro- 2. Dwyre DM et al. Hepatitis B, hepatitis C and HIV transfu- 9 patients with acute coronary syndrome. nary syndrome, stable CAD, and CHF, but sion-transmitted infections in the 21st century. Vox Sang. However, it remains controversial if adds that the “threshold of 7 g/dL is likely 2011;100:92-8. transfusion has benefit or causes harm in comparable with 8 g/dL, but randomized 3. Hébert PC et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. patients with acute coronary syndrome. No controlled trial evidence is not available for Transfusion Requirements in Critical Care Investiga- 1 randomized controlled trials have yet been all patient categories.” tors, Canadian Critical Care Trials Group. N Engl J Med. published on this topic, and observational Of note, certain patient populations, 1999;340:409-17. studies and subgroups from randomized such as those with end-stage renal disease, 4. Holst LB et al. Lower versus higher hemoglobin threshold for transfusion in septic shock. N Engl J Med. controlled trials have yielded mixed results. oncology patients (especially those under- 2014;371:1381-91. Similarly, there are no randomized going active chemotherapy), and those with 5. Villanueva C et al. Transfusion strategies for acute upper controlled trials examining liberal versus comorbid conditions such as thrombocy- gastrointestinal bleeding. N Engl J Med. 2013;368:11-21. restrictive transfusion goals for asympto- topenia and coagulopathy are specifically 6. Jairath V et al. Restrictive versus liberal blood transfu- matic hospitalized patients with stable excluded from the AABB guidelines. The sion for acute upper gastrointestinal bleeding (TRIGGER): a pragmatic, open-label, cluster randomised feasibility trial. coronary artery disease (CAD). However, reader is referred to guidelines from respec- Lancet. 2015;386:137-44. patients with CAD were included in the tive specialty societies for further guidance. 7. Hajjar LA et al. Transfusion requirements after cardiac 3,8 TRICC and FOCUS trials. Of patients surgery: the TRACS randomized controlled trial. JAMA. enrolled in the TRICC trial, 26% had a Back to our case 2010;304:1559-67. primary or secondary diagnosis of cardiac This 48-year-old man with cirrhosis and 8. Carson JL et al. Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med. disease; subgroup analysis found no esophageal varices presenting with ongo- 2011;365:2453-62. significant differences in 30-day mortal- ing blood loss due to hematochezia and 9. Sabatine MS et al. Association of hemoglobin levels with ity between treatment groups, similar hematemesis with a hemoglobin of 7.8 clinical outcomes in acute coronary syndromes. Circulation. to that of the entire study population. 3 g/dL should be transfused because of 2005;111:2042-9.

www.the-hospitalist.org I DECEMBER 2017 I THE HOSPITALIST 33 NEWS I Clinical developments, health care policy, and regulations Steroids underused in bacterial meningitis despite low risk

By Amy Karon associates analyzed the medical records of 120 “The difficult question is whether we give 4 days of Frontline Medical News adults with culture-confirmed, community- acquired bacterial meningitis treated at 10 steroids or longer. A clinical trial is not feasible, so we AT IDWEEK 2017 Houston-area hospitals between 2008 and SAN DIEGO – Physicians often skipped out 2016. [recommend] 4 days.” on using steroids when treating bacterial Median duration of steroid therapy was 4 meningitis even though the benefits clearly hours, which is consistent with IDSA guide- outweigh the risks, Cinthia Gallegos, MD, lines, she noted. where we did autopsies of cases, and we saw around 10% for meningitis associated with reported during an oral presentation at an Among the five patients (4%) who devel- a huge amount of bacterial fragments around Neisseria meningitides and Haemophilus influ- annual meeting on infectious diseases. oped delayed cerebral thrombosis, three had the blood vessels,” he said. “We have seen this enza infection, and often exceeded 30% for In a recent multicenter retrospective cohort Streptococcus pneumoniae meningitis, one had in previous autopsy studies, but here it was a S. pneumoniae meningitis. That’s important study, only 40% of adults with bacterial methicillin-resistant Staphylococcus aureus massive amount of bacterial fragments.” because, besides antibiotics, the only treat- meningitis received steroids within 4 hours meningitis, and one had Listeria meningitis. Researchers have suggested that delayed ment that decreases mortality has been shown of hospital admission, as recommended by All received either dexamethasone monother- cerebral thrombosis in bacterial meningitis to be steroids. the European Society of Clinical Microbiol- apy or dexamethasone and methylpredniso- results from increases in C5a and C5b-9 levels High-quality evidence supports their use. ogy and Infectious Diseases (ESCMID), and lone within 4 hours of antibiotic initiation. in the cerebrospinal fluid and from an increase In a double-blind, randomized, multicenter only 14% received steroids concomitantly or They showed an initial improvement, includ- in the tissue factor VII pathway. trial of 301 adults with bacterial meningitis, 10-20 minutes prior to antibiotic initiation, ing normal CT and MRI, but their clinical These patients historically developed vascu- adjunctive dexamethasone was associated with as recommended by the Infectious Diseases condition deteriorated between 5 and 12 litis, but this complication “has disappeared a 50% improvement in mortality, compared Society of America (IDSA), said Dr. Gallegos, days later. Two patients died, two developed somewhat in the dexamethasone era,” said with adjunctive placebo (N Engl J Med. an ID fellow at University of Texas, Houston. moderate or severe disability, and one fully Dr. van de Beek, lead author of the 2016 2002 Nov 14;347[20]:1549-56). Other data “Steroids are being underutilized in our recovered. ESCMID guidelines on bacterial meningi- confirm that steroids do not prevent vancomy- patient population,” she said. “And when ster- The 4% rate closely resembles what is seen tis. “It appears that some patients are ‘pro- cin from concentrating in CSF or increase the oids are used, they are being used later than is in the Netherlands, said Diederik van de Beek, inflammatory’ and still react 7-9 days after risk of hippocampal apoptosis. But although recommended.” MD, PhD, of the Academic Medical Center treatment,” he said. “The difficult question is both IDSA and ESCMID endorse steroids as To evaluate the prevalence of guideline- in Amsterdam, who co-moderated the session whether we give 4 days of steroids or longer. adjunctive therapy to help control intracranial concordant steroid use, Dr. Gallegos and her at IDWeek 2017. “We have some recent data A clinical trial is not feasible, so we [recom- pressure in patients with bacterial meningi- mend] 4 days.” tis, studies have shown much higher rates of Left untreated, bacterial meningitis is fatal steroid use in the Netherlands, Sweden, and in up to 70% of cases, and about one in five Denmark than in the United States. survivors faces limb loss or neurologic disa- The Grant A. Starr Foundation provided bility, according to the Centers for Disease funding. The investigators had no conflicts Control and Prevention. The advent of of interest. penicillin and other antibiotics dramatically More Than a improved survival, but death rates remained [email protected] Society, It’s a Firearms’ injury toll of $3 billion Movement. just ‘a drop in the bucket’ By Randy Dotinga appeared alive in emergency departments Become an SHM member today. Frontline Medical News over that period with firearms injuries, and they estimated the total weighted number at AT THE ACS CLINICAL CONGRESS 704,916. They found that the incidence of SAN DIEGO – The true impact of firearms firearms injury admissions actually fell during injuries may be greatly underestimated, 2006-2013 (from 27.9 visits per 100,000 according to a study presented at the Ameri- people to 21.5, P < .001) but bumped up by can College of Surgeons Clinical Congress. 23.7% to 26.6 during The study estimates that firearms injuries 2013-2014 (P < .001). cost nearly $3 billion a year in emergency The average costs of department and inpatient treatment costs. emergency and inpa- The real cost is likely to be 10-20 times higher, tient care for patients said the lead author of the study, Faiz Gani, injured by firearms MD, a research fellow with the Johns Hopkins were $5,254 and Surgery Center for Outcomes Research, Balti- $95,887, respectively, more. collectively amounting Dr. Gani and his colleagues launched their Dr. Gani to about $2.8 billion study (Health Affairs 2017;36[10]:1729-38) each year. Dr. Gani said to better understand the cost of firearms inju- that the estimation of the cost and impact of ries, including nonfatal or accidental injuries. firearms injuries don’t account for people who Most estimates of the cost of firearm inju- died of firearms injuries before reaching the ries are outdated or focused on states or single ED. trauma centers, he said. The cost estimates also don’t take follow- The researchers retrospectively analyzed up care, rehabilitation, and lifelong disability hospitalmedicine.org data from the Nationwide Emergency into account. The surgical portion of the cost Department Sample of the Healthcare Cost is likely to be much higher, he said. and Utilization Project for the years 2006- 2014. They identified 150,930 patients who [email protected]

34 THE HOSPITALIST I DECEMBER 2017 I www.the-hospitalist.org Carvedilol fails to reduce variceal bleeds in acute-on-chronic liver failure

By Denise Fulton failure in most). Mean Model for End-Stage Treatment with carvedilol Frontline Medical News Liver Disease (MELD) scores were about 25. Hemodynamic parameters also were did not achieve signifi- AT THE LIVER MEETING 2017 comparable, with a mean HVPG of about WASHINGTON – Treatment with carve- 19 mm Hg, Dr. Kainth said at the annual cant reductions in variceal dilol reduced the incidence of sepsis and meeting of the American Association for the acute kidney injury and improved survival Study of Liver Diseases. bleeding, “possibly due to at 28 days but did not significantly reduce Patients in the treatment group received a the progression of esophageal varices in median maximum tolerated dose of carvedilol the low number of bleeds patients with acute-on-chronic liver failure. of 12.5 mg, with a range of 3.13 mg to 25 mg. seen in the study [because A total of 136 patients with acute-on- Morbidity and mortality were high, as is chronic liver failure with small or no esoph- expected with acute-on-chronic liver fail- of] the exclusion of patients ageal varices and a hepatic venous pressure ure, he noted. A total of 36 patients died gradient (HVPG) of 12 mm Hg or greater before the end of the 90-day study period. with large varices.” were enrolled in a single-center, prospective, Another 23 experienced adverse events and open-label, randomized controlled trial: 66 2 progressed to liver transplant. –Sumeet Kainth, MD were randomized to carvedilol and 70 to HVPG at 90 days decreased significantly in placebo, according to Sumeet Kainth, MD, both groups. In the carvedilol group, 90-day of the Institute of Liver and Biliary Sciences HVPG was 16 mm Hg, compared with 19.7 Dr. Kainth said. At 90 days, varices had significant reductions in variceal bleeding, in New Delhi. mm Hg at baseline (P less than .01). For progressed in 9 of 40 patients (22.5%) of “possibly due to the low number of bleeds More than 90% of patients were men placebo patients, 90-day HVPG spontane- patients on carvedilol and 8 of 31 (25.8%) seen in the study [because of] the exclusion with a mean age of 44 years, and composi- ously improved to 14.8 mm Hg from the of placebo patients. of patients with large varices,” Dr. Kainth said. tion of the treatment and placebo groups baseline of 17.2 mm Hg (P less than .01). Significantly fewer patients in the carve- The study was sponsored by Institute was similar. About 70% in each group had Carvedilol did not significantly slow the dilol group developed acute kidney injury at of Liver and Biliary Sciences. Dr. Kainth alcoholic hepatitis (the reason for acute liver development or growth of varices, however, 28 days (14% vs. 38% on placebo) and sepsis reported no relevant conflicts of interest. (5% vs. 20%). Mortality also was reduced significantly at 28 days (11% vs. 24%). [email protected] Wait 2+ days to replace CVCs Treatment with carvedilol did not achieve On Twitter @denisefulton in patients with candidemia Symptoms: x x By Amy Karon after removal in 87% of patients who died and Tired. Frustrated. x Loss of time navigating. Frontline Medical News in 54% of survivors (P = .04). The association remained statistically significant after the AT IDWEEK 2017 researchers accounted for potential confound- SHM’s Prescription: SAN DIEGO – Wait at least 2 days before ers (adjusted odds ratio, 5.9; 95% confidence replacing central venous catheters (CVC) in interval, 1.2-29.7; P = .03). patients with catheter-associated candidemia, Patients who died within 30 days of CVC according to the results of a single-center replacement also were more likely to have Brand New retrospective cohort study of 228 patients. hematologic malignancies (20% versus 4%), Waiting less than 2 days to replace a CVC to have diabetes (13% vs. 11%), to be on increased the odds of 30-day mortality nearly hemodialysis (27% vs. 16%), and to have sixfold among patients with catheter-related a history of recent corticosteroid exposure Website. bloodstream infections due to candidemia, (20% versus 11%) compared with survi- even after controlling for potential confound- vors, but none of these associations reached ers, Takahiro Matsuo, MD, said at an annual statistical significance. Furthermore, 30-day Coming Soon! scientific meeting on infectious diseases. No mortality was not associated with gender, other factor significantly predicted mortal- age, Candida species, endophthalmitis, or ity in univariate or multivariate analyses, he type of antifungal therapy, said Dr. Matsuo, said. “This is the first study to demonstrate who spoke at the combined annual meetings the optimal timing of central venous catheter of the Infectious Diseases Society of America, replacement in catheter-related [bloodstream the Society for Healthcare Epidemiology of infection] due to Candida.” America, the HIV Medicine Association, and Invasive candidiasis is associated with the Pediatric Infectious Diseases Society. mortality rates of up to 50%, noted Dr. An infectious disease consultation was Matsuo, who is a fellow in infectious associated with about a 70% reduction in the diseases at St. Luke’s International Hospi- odds of mortality in the multivariate analysis, tal, Tokyo. Antifungal therapy improves but the 95% confidence interval crossed 1.0, outcomes, and most physicians agree rendering the link statistically insignificant. that removing a CVC does, too. To better Given the small sample size and single- pinpoint optimal timing of catheter replace- center design of this study, its findings ment, Dr. Matsuo and his associates exam- ideally should be confirmed in a larger rand- ined risk factors for 30-day mortality among omized controlled trial, Dr. Matsuo said. patients with candidemia who were treated The investigators also did not track whether at St. Luke’s between 2004 and 2015. patients were fungemic at the time of CVC Among 228 patients with candidemia, 166 replacement, he noted. had CVCs, and 144 had their CVC removed. The researchers reported having no Empowering hospitalists. Among 71 patients who needed their CVC conflicts of interest. hospitalmedicine.org Transforming patient care. replaced, 15 died within 30 days. Central venous catheters were replaced less than 2 days [email protected]

www.the-hospitalist.org I DECEMBER 2017 I THE HOSPITALIST 35 NEWS I Clinical developments, health care policy, and regulations VA study finds high MRSA infection risk among those colonized with the bacterium

By Doug Brunk MRSA infections in these individuals prior Frontline Medical News to discharge and at 30 and 90 days post discharge. Infections were defined as posi- AT FROM ID WEEK 2017 tive MRSA cultures taken from sterile sites, SAN DIEGO – Patients colonized with methi- including blood, catheter site, or bone. cillin-resistant Staphylococcus aureus are at high Overall, patients were in their mid-60s, risk of MRSA infection both in the predis- and those who imported MRSA and those charge and postdischarge time periods, results who acquired it were more likely to be male, from an 8-year Veterans Affairs study showed. less likely to be married, and more likely “MRSA colonization is recognized as being to not have health insurance. “The acquir- a strong predictor of subsequent infection,” ers had by far the highest rates of predis- Richard E. Nelson, PhD, said at an annual charge infections, which peaked in 2010 scientific meeting on infectious diseases. and declined through 2015,” said Dr. “What’s less understood is, are there differ- Nelson, who also holds a faculty position in ences in infection rates among patients who University of Utah’s department of internal are colonized at different times? And, is there medicine, in the division of epidemiology. a difference between patients who import Specifically, the proportion of predischarge colonization with them to a hospital versus MRSA infections, compared with 30 days those who acquire it during a hospital stay? post discharge, were 40.4% vs. 59.6%, In addition, infection control efforts mainly respectively, in the no colonization group; focus on the predischarge time period. What 63% vs. 37% in the importation group; and about infections that develop post discharge?” 80.8% vs. 19.2% in the acquisition group. In an effort to investigate these ques- He also reported that the proportion of tions, Dr. Nelson of the VA Salt Lake City predischarge MRSA infections, compared “This is likely an underestimate of postdischarge Healthcare System, and his associates, with 90 days post discharge, were 20.5% vs. evaluated more than 1.3 million acute care 79.5%, respectively, in the no colonization infections, because we’re missing the infections that inpatient admissions to 125 VA hospitals group; 47.3% vs. 52.7% in the importation nationwide from January 2008 through group; and 70.5% vs. 29.5% in the acquisition occur in non-VA facilities.” December 2015 who had surveillance tests group. The time from acquisition to infection performed for MRSA carriage. was a mean of 8.7 days in the 30-day analysis The researchers restricted admissions to and a mean of 22.4 days in the 90-day analysis. discharge 30 days, and OR 8.26 at post- cine Association, and the Pediatric Infec- individuals with at least 365 days of VA Multivariate logistic regression revealed discharge 90 days (P less than .001 for all). tious Diseases Society. “Also, patients can be activity prior to admission and catego- that the impact of colonization status on Dr. Nelson acknowledged certain limita- colonized in many different body locations, rized them into three groups: no coloniza- infection was highest in the acquisition tions of the study, including the fact that it but the VA protocol is that the surveillance tion (defined as those who had no positive group, compared with the importation only identified postdischarge infections that test be done in the nostrils. So we may have surveillance tests (n = 1,196,928); impor- group. Specifically, the odds ratio of devel- were detected in a VA facility. “This is likely misclassified patients who were colonized in tation (defined as those who tested posi- oping a MRSA infection among the impor- an underestimate of postdischarge infec- a different body location as being uncolo- tive for MRSA colonization on admission tation group was 29.22 in the predischarge tions, because we’re missing the infections nized, when in fact they were colonized.” (n = 95,833); and acquisition (defined as period, OR 10.87 at postdischarge 30 days, that occur in non-VA facilities,” he said at the The study was funded by a grant from the those who did not test positive for MRSA and OR 7.64 at postdischarge 90 days (P event, which marked the combined annual VA. Dr. Nelson reported having no finan- on admission but tested positive on a subse- less than .001 for all). Meanwhile, the OR meetings of the Infectious Diseases Soci- cial disclosures. quent surveillance test during their admis- among the acquisition group was 85.19 in ety of America, the Society for Healthcare sion (n = 15,146). Next, they captured the predischarge period, OR 13.01 at post- Epidemiology of America, the HIV Medi- [email protected] Negative nasal swabs reliably predicted no MRSA infection

By Amy Karon tion, but guidelines don’t address how to use swab results to curtail vancomycin therapy, guidelines for antibiotic use, which are avail- Frontline Medical News swab results to guide decisions about empiric she found. Rates of empiric vancomycin able in an app for Johns Hopkins providers, vancomycin, Dr. Chotiprasitsakul said. use were 36% among patients with positive she said in an interview. AT IDWEEK 2017 Therefore, she and her associates studied swabs and 39% among those with nega- The stewardship also highlights the data SAN DIEGO – Only 0.2% of intensive 11,882 adults with- tive swabs. Over 19 months, ICU patients when discussing starting and stopping vanco- care–unit patients developed methicillin- out historical MRSA received 7,371 avoidable days of vancomy- mycin in patients at very low risk for MRSA resistant Staphylococcus aureus infections infection or coloni- cin, a median of 3 days per patient. infections, she said. “In general, providers after testing negative on nasal surveillance zation who received Matching patients by ICU and days at have responded favorably to acting upon swabs, said Darunee Chotiprasitsakul, MD, nasal swabs for risk identified no significant predictors of this new information,” Dr. Cosgrove noted. of Johns Hopkins University in Baltimore. routine surveillance MRSA infection, Dr. Chotiprasitsakul said. Johns Hopkins continues to track median But physicians often prescribed vanco- in adult ICUs at Johns Johns Hopkins Medicine has robust infec- days of vancomycin use per patient and per mycin anyway, accumulating nearly 7,400 Hopkins. A total of tion control practices, high compliance with 1,000 days in its units. “[We] will assess if potentially avoidable treatment-days over 441 patients (4%) had hand hygiene and contact precautions, and there is an impact on vancomycin use over a 19-month period, she said during an oral positive swabs, while Dr. Chotiprasitsakul low rates of nosocomial MRSA transmission, the coming year,” said Dr. Cosgrove. presentation at an annual meeting on infec- 96% tested negative. she noted. The predictive value of a negative The investigators had no conflicts of inter- tious diseases. Among patients with negative swabs, MRSA nasal swab could be lower at institu- est. The event marked the combined annual Current guidelines recommend empiric only 25 (0.22%) developed MRSA infections where that isn’t the case, she said. meetings of the Infectious Diseases Soci- vancomycin to cover MRSA infection when tion requiring treatment. Thus, the negative Johns Hopkins is working to curtail ety of America, the Society for Healthcare ill patients have a history of MRSA coloni- predictive value of a nasal swab for MRSA unnecessary use of vancomycin, said senior Epidemiology of America, the HIV Medi- zation or recent hospitalization or exposure was 99%, making the probability of infec- author Sara Cosgrove, MD, professor of cine Association, and the Pediatric Infectious to antibiotics. Patients whose nasal screen- tion despite a negative swab “exceedingly medicine in infectious diseases and director Diseases Society. ing swabs are negative for MRSA have been low,” Dr. Chotiprasitsakul said. of the department of antimicrobial steward- shown to be at low risk of subsequent infec- But clinicians seemed not to use negative ship. The team has added the findings to its [email protected]

36 THE HOSPITALIST I DECEMBER 2017 I www.the-hospitalist.org Study: EHR malpractice claims rising

By Alicia Gallegos and a member of the board of governors for “This study makes an important contribution Frontline Medical News The Doctors Company. “This study makes an important contri- by chronicling actual errors, such as wrong alpractice claims involving the use bution by chronicling actual errors, such Mof electronic health records are on as wrong medications selected from an medications selected from an autopick list, the rise, according to data from The autopick list, and helps point the way to Doctors Company. changes ranging from physician education and helps point the way to changes ranging Cases in which EHRs were a factor grew to EHR software design,” Dr. Wachter said from 2 claims during 2007-2010 to 161 in a statement. from physician education to EHR software claims from 2011 to December 2016, design.” according an analysis published Oct. 16 by [email protected] The Doctors Company, a national medical On Twitter @legal_med –Robert M. Wachter, MD malpractice insurer. Researchers with The Doctors Company analyzed closed claims during 2007-2016 in their nationwide claims database. Of 66 EHR-related claims from July 2014 through December 2016, 50% were associated with system factors, such as failure of drug or clinical decision support alerts, according to the study. Another 58% of claims involved user factors, such as copy- ing and pasting progress notes. (Numbers do not add up to 100% because some claims had more than one cause.) The majority of EHR-related claims during 2014-2016 stemmed from inci- dents in a doctor’s office or a hospital clinic (35%), while the second most common location was a patient’s room. Malpractice claims involving EHRs were most commonly alleged against ob.gyns, followed by family physicians, and ortho- pedists. Diagnosis errors and improper medication management were the top most frequent allegations associated with EHR claims. The analysis shows that, while digiti- zation of medicine has improved patient safety, it also has a dark side – as evidenced by the emergence of new kinds of errors, said Robert M. Wachter, MD, a professor at the University of California, San Francisco,

www.the-hospitalist.org I NOVEMBER 2017 I THE HOSPITALIST 37 PROTONIX® (pantoprazole sodium)

BRIEF SUMMARY OF PRESCRIBING INFORMATION. at high dose; see methotrexate prescribing information) may shock), systemic lupus erythematosus of PROTONIX (approximating 0.6 mg/kg or 1.2 mg/kg). All 4 of SEE PACKAGE INSERT FOR FULL PRESCRIBING elevate and prolong serum levels of methotrexate and/or its Infections and Infestations: Clostridium difficile these patients with EE were healed (Hetzel-Dent score of 0 or 1) INFORMATION. metabolite, possibly leading to methotrexate toxicities. In high-dose associated diarrhea at 8 weeks. Because EE is uncommon in the pediatric population, methotrexate administration, a temporary withdrawal of the PPI predominantly pediatric patients with endoscopically-proven or INDICATIONS AND USAGE Investigations: weight changes may be considered in some patients. symptomatic GERD were also included in these studies. Patients PROTONIX For Delayed-Release Oral Suspension and PROTONIX Metabolism and Nutritional Disorders: hyponatremia, Interference with Laboratory Tests Use of PPIs, including were treated with a range of doses of PROTONIX once daily for Delayed-Release Tablets are indicated for: hypomagnesemia pantoprazole, may increase chromogranin A (CgA) levels which 8 weeks. For safety findings see Adverse Reactions. Because Short-Term Treatment of Erosive Esophagitis Associated may interfere with investigations for neuroendocrine tumors. To Musculoskeletal Disorders: rhabdomyolysis, bone fracture these pediatric trials had no placebo, active comparator, or With Gastroesophageal Reux Disease (GERD) PROTONIX is avoid this interference, PPI treatment should be stopped 14 days Nervous: ageusia, dysgeusia evidence of a dose response, the trials were inconclusive indicated in adults and pediatric patients five years of age and before CgA measurements. Psychiatric Disorders: hallucination, confusion, regarding the clinical benefit of PROTONIX for symptomatic older for the short-term treatment (up to 8 weeks) in the healing insomnia, somnolence GERD in the pediatric population. The effectiveness of PROTONIX and symptomatic relief of erosive esophagitis. For those adult ADVERSE REACTIONS for treating symptomatic GERD in pediatric patients has not been patients who have not healed after 8 weeks of treatment, an The following serious adverse reactions are described below and Renal and Urinary Disorders: interstitial nephritis established. additional 8-week course of PROTONIX may be considered. Safety elsewhere in labeling: Skin and Subcutaneous Tissue Disorders: severe dermatologic Although the data from the clinical trials support use of PROTONIX of treatment beyond 8 weeks in pediatric patients has not been • Acute Interstitial Nephritis reactions (some fatal), including erythema multiforme, Stevens- for the short-term treatment of EE associated with GERD in Johnson syndrome, toxic epidermal necrolysis (TEN, some established. • Clostridium difficile-Associated Diarrhea pediatric patients 1 year through 5 years, there is no commercially fatal), angioedema (Quincke’s edema) and cutaneous lupus Maintenance of Healing of Erosive Esophagitis PROTONIX is • Bone Fracture available dosage formulation appropriate for patients less than indicated for maintenance of healing of erosive esophagitis and erythematosus 5 years of age. • Cutaneous and Systemic Lupus Erythematosus reduction in relapse rates of daytime and nighttime heartburn DRUG INTERACTIONS In a population pharmacokinetic analysis, clearance values in • Cyanocobalamin (Vitamin B-12) Deficiency symptoms in adult patients with GERD. Controlled studies did not Interference with Antiretroviral Therapy Concomitant use the children 1 to 5 years old with endoscopically proven GERD extend beyond 12 months. • Hypomagnesemia of atazanavir or nelfinavir with proton pump inhibitors is not had a median value of 2.4 L/h. Following a 1.2 mg/kg equivalent Pathological Hypersecretory Conditions Including Clinical Trials Experience The adverse reaction profiles for recommended. Co-administration of atazanavir or nelfinavir with dose (15 mg for ≤ 12.5 kg and 20 mg for >12.5 to < 25 kg), the Zollinger-Ellison Syndrome PROTONIX is indicated for the long- PROTONIX (pantoprazole sodium) For Delayed-Release Oral proton pump inhibitors is expected to substantially decrease plasma concentrations of pantoprazole were highly variable and term treatment of pathological hypersecretory conditions, including Suspension and PROTONIX (pantoprazole sodium) Delayed- atazanavir or nelfinavir plasma concentrations and may result in a the median time to peak plasma concentration was 3 to 6 hours. Zollinger-Ellison syndrome. Release Tablets are similar. loss of therapeutic effect and development of drug resistance. The estimated AUC for patients 1 to 5 years old was 37% higher CONTRAINDICATIONS Because clinical trials are conducted under widely varying Coumarin Anticoagulants There have been postmarketing than for adults receiving a single 40 mg tablet, with a geometric mean AUC value of 6.8 µg∙hr/mL. PROTONIX is contraindicated in patients with known hypersensitivity conditions, adverse reaction rates observed in the clinical trials reports of increased INR and prothrombin time in patients to any component of the formulation or any substituted of a drug cannot be directly compared to rates in the clinical receiving proton pump inhibitors, including PROTONIX, and Neonates to less than one year of age PROTONIX was benzimidazole. Hypersensitivity reactions may include anaphylaxis, trials of another drug and may not reflect the rates observed in warfarin concomitantly. Increases in INR and prothrombin time not found to be effective in a multicenter, randomized, double- anaphylactic shock, angioedema, bronchospasm, acute interstitial clinical practice. may lead to abnormal bleeding and even death. Patients treated blind, placebo-controlled, treatment-withdrawal study of 129 nephritis, and urticaria. Adults Safety in nine randomized comparative US clinical trials with proton pump inhibitors and warfarin concomitantly should be pediatric patients 1 through 11 months of age. Patients were in patients with GERD included 1,473 patients on oral monitored for increases in INR and prothrombin time. enrolled if they had symptomatic GERD based on medical history WARNINGS AND PRECAUTIONS and had not responded to non-pharmacologic interventions for PROTONIX (20 mg or 40 mg), 299 patients on an H2-receptor Clopidogrel Concomitant administration of pantoprazole and Presence of Gastric Malignancy In adults, symptomatic antagonist, 46 patients on another proton pump inhibitor, and clopidogrel in healthy subjects had no clinically important effect on GERD for two weeks. Patients received PROTONIX daily for four response to therapy with PROTONIX does not preclude the 82 patients on placebo. The most frequently occurring adverse exposure to the active metabolite of clopidogrel or clopidogrel- weeks in an open-label phase, then patients were randomized in presence of gastric malignancy. Consider additional follow-up reactions are listed in table below. induced platelet inhibition. No dose adjustment of clopidogrel equal proportion to receive PROTONIX treatment or placebo for and diagnostic testing in adult patients who have a suboptimal is necessary when administered with an approved dose of the subsequent four weeks in a double-blind manner. Efficacy response or an early symptomatic relapse after completing Adverse Reactions Reported in Clinical Trials of PROTONIX. was assessed by observing the time from randomization to treatment with a PPI. In older patients, also consider an endoscopy. Adult Patients with GERD at a Frequency of > 2% Drugs for Which Gastric pH Can Affect Bioavailability Due study discontinuation due to symptom worsening during the Acute Interstitial Nephritis Acute interstitial nephritis has been to its effects on gastric acid secretion, pantoprazole can reduce four-week treatment-withdrawal phase. There was no statistically observed in patients taking PPIs including PROTONIX. Acute PROTONIX Comparators Placebo significant difference between PROTONIX and placebo in the rate (n=1473) % (n=345) % (n=82) % the absorption of drugs where gastric pH is an important interstitial nephritis may occur at any point during PPI therapy and determinant of their bioavailability. Like with other drugs that of discontinuation. is generally attributed to an idiopathic hypersensitivity reaction. Headache 12.2 12.8 8.5 decrease the intragastric acidity, the absorption of drugs such as In this trial, the adverse reactions that were reported more Discontinue PROTONIX if acute interstitial nephritis develops. ketoconazole, ampicillin esters, atazanavir, iron salts, erlotinib, and commonly (difference of ≥ 4%) in the treated population compared Clostridium difficile-Associated Diarrhea Published Diarrhea 8.8 9.6 4.9 mycophenolate mofetil (MMF) can decrease. to the placebo population were elevated CK, otitis media, rhinitis, and laryngitis. observational studies suggest that PPI therapy like PROTONIX Nausea 7.0 5.2 9.8 Co-administration of pantoprazole in healthy subjects and in may be associated with an increased risk of Clostridium difficile transplant patients receiving MMF has been reported to reduce In a population pharmacokinetic analysis, the systemic exposure associated diarrhea, especially in hospitalized patients. This Abdominal 6.2 4.1 6.1 the exposure to the active metabolite, mycophenolic acid (MPA), was higher in patients less than 1 year of age with GERD diagnosis should be considered for diarrhea that does not improve. pain possibly due to a decrease in MMF solubility at an increased compared to adults who received a single 40 mg dose (geometric Patients should use the lowest dose and shortest duration of PPI Vomiting 4.3 3.5 2.4 gastric pH. The clinical relevance of reduced MPA exposure on mean AUC was 103% higher in preterm infants and neonates therapy appropriate to the condition being treated. organ rejection has not been established in transplant patients receiving single dose of 2.5 mg of PROTONIX, and 23% higher Bone Fracture Several published observational studies suggest Flatulence 3.9 2.9 3.7 receiving PROTONIX and MMF. Use PROTONIX with caution in in infants 1 through 11 months of age receiving a single dose that proton pump inhibitor (PPI) therapy may be associated with transplant patients receiving MMF. of approximately 1.2 mg/kg). In these patients, the apparent an increased risk for osteoporosis-related fractures of the hip, Dizziness 3.0 2.9 1.2 False Positive Urine Tests for THC There have been reports clearance (CL/F) increased with age (median clearance: 0.6 L/hr, range: 0.03 to 3.2 L/hr). wrist, or spine. The risk of fracture was increased in patients who Arthralgia 2.8 1.4 1.2 of false positive urine screening tests for tetrahydrocannabinol received high-dose, defined as multiple daily doses, and long-term (THC) in patients receiving proton pump inhibitors. An alternative These doses resulted in pharmacodynamic effects on gastric PPI therapy (a year or longer). Patients should use the lowest dose Additional adverse reactions that were reported for PROTONIX in confirmatory method should be considered to verify positive but not esophageal pH. Following once daily dosing of 2.5 mg of and shortest duration of PPI therapy appropriate to the condition clinical trials with a frequency of ≤ 2% are listed below by body results. PROTONIX in preterm infants and neonates, there was an increase being treated. Patients at risk for osteoporosis-related fractures system: Methotrexate Case reports, published population pharmacokinetic in the mean gastric pH (from 4.3 at baseline to 5.2 at steady- should be managed according to established treatment guidelines. Body as a Whole: allergic reaction, pyrexia, photosensitivity studies, and retrospective analyses suggest that concomitant state) and in the mean % time that gastric pH was > 4 (from 60% Cutaneous and Systemic Lupus Erythematosus Cutaneous reaction, facial edema administration of PPIs and methotrexate (primarily at high at baseline to 80% at steady-state). Following once daily dosing of approximately 1.2 mg/kg of PROTONIX in infants 1 through lupus erythematosus (CLE) and systemic lupus erythematosus Gastrointestinal: constipation, dry mouth, hepatitis dose; see methotrexate prescribing information) may elevate (SLE) have been reported in patients taking PPIs, including 11 months of age, there was an increase in the mean gastric pH Hematologic: leukopenia, thrombocytopenia and prolong serum levels of methotrexate and/or its metabolite pantoprazole. These events have occurred as both new onset and hydroxymethotrexate. However, no formal drug interaction studies (from 3.1 at baseline to 4.2 at steady-state) and in the mean % an exacerbation of existing autoimmune disease. The majority of Metabolic/Nutritional: elevated CK (creatine kinase), generalized of Methotrexate with PPIs have been conducted. time that gastric pH was > 4 (from 32% at baseline to 60% at edema, elevated triglycerides, liver enzymes elevated steady-state). However, no significant changes were observed in PPI-induced lupus erythematous cases were CLE. USE IN SPECIFIC POPULATIONS Musculoskeletal: myalgia mean intraesophageal pH or % time that esophageal pH was < 4 The most common form of CLE reported in patients treated Pregnancy in either age group. with PPIs was subacute CLE (SCLE) and occurred within weeks Nervous: depression, vertigo Teratogenic Effects Because PROTONIX was not shown to be effective in the to years after continuous drug therapy in patients ranging Skin and Appendages: urticaria, rash, pruritus Pregnancy Category B Reproduction studies have been randomized, placebo-controlled study in this age group, the use of from infants to the elderly. Generally, histological findings were Special Senses: blurred vision observed without organ involvement. performed in rats at oral doses up to 88 times the recommended PROTONIX for treatment of symptomatic GERD in infants less than Pediatric Patients Safety of PROTONIX in the treatment of Erosive human dose and in rabbits at oral doses up to 16 times the 1 year of age is not indicated. Systemic lupus erythematosus (SLE) is less commonly reported Esophagitis (EE) associated with GERD was evaluated in pediatric than CLE in patients receiving PPIs. PPI associated SLE is usually recommended human dose and have revealed no evidence of Geriatric Use In short-term US clinical trials, erosive esophagitis patients ages 1 year through 16 years in three clinical trials. impaired fertility or harm to the fetus due to pantoprazole. There healing rates in the 107 elderly patients (≥ 65 years old) treated milder than non-drug induced SLE. Onset of SLE typically occurred Safety trials involved pediatric patients with EE; however, as EE is within days to years after initiating treatment primarily in patients are, however, no adequate and well-controlled studies in pregnant with PROTONIX were similar to those found in patients under the uncommon in the pediatric population, 249 pediatric patients with women. Because animal reproduction studies are not always age of 65. The incidence rates of adverse reactions and laboratory ranging from young adults to the elderly. The majority of patients endoscopically-proven or symptomatic GERD were also evaluated. presented with rash; however, arthralgia and cytopenia were also predictive of human response, this drug should be used during abnormalities in patients aged 65 years and older were similar to All adult adverse reactions to PROTONIX are considered relevant pregnancy only if clearly needed. those associated with patients younger than 65 years of age. reported. to pediatric patients. In patients ages 1 year through 16 years, the Nursing Mothers Pantoprazole and its metabolites are excreted Gender Erosive esophagitis healing rates in the 221 women Avoid administration of PPIs for longer than medically indicated. most commonly reported (> 4%) adverse reactions include: URI, in the milk of rats. Pantoprazole excretion in human milk has been treated with PROTONIX Delayed-Release Tablets in US clinical If signs or symptoms consistent with CLE or SLE are noted in headache, fever, diarrhea, vomiting, rash, and abdominal pain. detected in a study of a single nursing mother after a single trials were similar to those found in men. In the 122 women patients receiving PROTONIX, discontinue the drug and refer the Additional adverse reactions that were reported for PROTONIX in patient to the appropriate specialist for evaluation. Most patients 40 mg oral dose. The clinical relevance of this finding is not treated long-term with PROTONIX 40 mg or 20 mg, healing was pediatric patients in clinical trials with a frequency of ≤ 4% are known. Many drugs which are excreted in human milk have a maintained at a rate similar to that in men. The incidence rates of improve with discontinuation of the PPI alone in 4 to 12 weeks. listed below by body system: Serological testing (e.g. ANA) may be positive and elevated potential for serious adverse reactions in nursing infants. Based adverse reactions were also similar for men and women. serological test results may take longer to resolve than clinical Body as a Whole: allergic reaction, facial edema on the potential for tumorigenicity shown for pantoprazole in Patients with Hepatic Impairment Doses higher than 40 mg/day manifestations. Gastrointestinal: constipation, flatulence, nausea rodent carcinogenicity studies, a decision should be made have not been studied in patients with hepatic impairment. Metabolic/Nutritional: elevated triglycerides, elevated whether to discontinue nursing or to discontinue the drug, OVERDOSAGE Cyanocobalamin (Vitamin B-12) Deciency Generally, taking into account the benefit of the drug to the mother. daily treatment with any acid-suppressing medications over liver enzymes, elevated CK (creatine kinase) Experience in patients taking very high doses of PROTONIX (> 240 a long period of time (e.g., longer than 3 years) may lead to Musculoskeletal: arthralgia, myalgia Pediatric Use The safety and effectiveness of PROTONIX for short-term treatment (up to eight weeks) of erosive esophagitis mg) is limited. Spontaneous post-marketing reports of overdose malabsorption of cyanocobalamin (Vitamin B-12) caused by Nervous: dizziness, vertigo are generally within the known safety profile of PROTONIX. hypo- or achlorhydria. Rare reports of cyanocobalamin deficiency (EE) associated with GERD have been established in pediatric Skin and Appendages: urticaria Pantoprazole is not removed by hemodialysis. In case of occurring with acid-suppressing therapy have been reported patients 1 year through 16 years of age. Effectiveness for EE overdosage, treatment should be symptomatic and supportive. in the literature. This diagnosis should be considered if clinical The following adverse reactions seen in adults in clinical trials has not been demonstrated in patients less than 1 year of age. symptoms consistent with cyanocobalamin deficiency are were not reported in pediatric patients in clinical trials, but are In addition, for patients less than 5 years of age, there is no Single oral doses of pantoprazole at 709 mg/kg, 798 mg/kg, and observed. considered relevant to pediatric patients: photosensitivity reaction, appropriate dosage strength in an age-appropriate formulation 887 mg/kg were lethal to mice, rats, and dogs, respectively. The dry mouth, hepatitis, thrombocytopenia, generalized edema, available. Therefore, PROTONIX is indicated for the short-term symptoms of acute toxicity were hypoactivity, ataxia, hunched Hypomagnesemia Hypomagnesemia, symptomatic and depression, pruritus, leukopenia, and blurred vision. treatment of EE associated with GERD for patients 5 years and sitting, limb-splay, lateral position, segregation, absence of ear asymptomatic, has been reported rarely in patients treated with Zollinger-Ellison Syndrome In clinical studies of Zollinger-Ellison older. The safety and effectiveness of PROTONIX for pediatric uses reflex, and tremor. PPIs for at least three months, in most cases after a year of other than EE have not been established. therapy. Serious adverse events include tetany, arrhythmias, and Syndrome, adverse reactions reported in 35 patients taking Storage Store PROTONIX For Delayed-Release Oral Suspension seizures. In most patients, treatment of hypomagnesemia required PROTONIX 80 mg/day to 240 mg/day for up to 2 years were 1 year through 16 years of age Use of PROTONIX in pediatric and PROTONIX Delayed-Release Tablets at 20° to 25°C (68° to magnesium replacement and discontinuation of the PPI. similar to those reported in adult patients with GERD. patients 1 year through 16 years of age for short-term treatment 77°F); excursions permitted to 15° to 30°C (59° to 86°F). Postmarketing Experience The following adverse reactions have (up to eight weeks) of EE associated with GERD is supported by: For patients expected to be on prolonged treatment or who take a) extrapolation of results from adequate and well-controlled This brief summary is based on PROTONIX Prescribing PPIs with medications such as digoxin or drugs that may cause been identified during postapproval use of PROTONIX. Because Information. these reactions are reported voluntarily from a population of studies that supported the approval of PROTONIX for treatment of hypomagnesemia (e.g., diuretics), health care professionals may EE associated with GERD in adults, and b) safety, effectiveness, LAB-0459-11.0, revised February 2017. consider monitoring magnesium levels prior to initiation of PPI uncertain size, it is not always possible to reliably estimate their and pharmacokinetic studies performed in pediatric patients. Under license from Takeda, D78467 Konstanz, Germany treatment and periodically. frequency or establish a causal relationship to drug exposure. These adverse reactions are listed below by body system: Safety of PROTONIX in the treatment of EE associated with GERD Tumorigenicity Due to the chronic nature of GERD, there may be in pediatric patients 1 through 16 years of age was evaluated in General Disorders and Administration Conditions: asthenia, fatigue, PP-PRX-USA-0158-04 © 2017 Pfizer Inc. All rights reserved. May 2017 a potential for prolonged administration of PROTONIX. In long-term three multicenter, randomized, double-blind, parallel-treatment malaise rodent studies, pantoprazole was carcinogenic and caused rare studies, involving 249 pediatric patients, including 8 with EE types of gastrointestinal tumors. The relevance of these findings to Hematologic: pancytopenia, agranulocytosis (4 patients ages 1 year to 5 years and 4 patients 5 years to 11 tumor development in humans is unknown. Hepatobiliary Disorders: hepatocellular damage leading to jaundice years). The children ages 1 year to 5 years with endoscopically Concomitant Use of PROTONIX with Methotrexate Literature and hepatic failure diagnosed EE (defined as an endoscopic Hetzel-Dent score ≥ 2) suggests that concomitant use of PPIs with methotrexate (primarily Immune System Disorders: anaphylaxis (including anaphylactic were treated once daily for 8 weeks with one of two dose levels

HOSP_38.indd 1 5/18/2017 11:38:31 AM NEWS I Clinical developments, health care policy, and regulations Ideal intubation position still unknown

By Andrew D. Bowser randomized trial with a primary endpoint of Frontline Medical News lowest arterial oxygen saturation, hypothesiz- ing that the endpoint would be higher for the FROM CHEST ramped position: “Our primary outcome of Valuable new data amid n critically ill adults undergoing endo- lowest arterial oxygen saturation is an estab- Itracheal intubation, the ramped position lished endpoint in ICU intubation trials, and does not significantly improve oxygen- is linked to periprocedural cardiac arrest and sparse literature ation compared with the sniffing posi- death,” they wrote. tion, according to results of a multicenter, The investigators instead found that Editorialists praised the multicent- study could contribute to the diver- randomized trial of 260 patients treated in median lowest arterial oxygen saturation was er, randomized design of this study, gences between this intensive care an intensive care unit. not statistically different between groups, at and its total recruitment of 260 unit experience and the operating Moreover, “[ramped] position appeared 93% for the ramped position, and 92% for patients. They also noted several room literature. The operating room to worsen glottic view and increase the the sniffing position (P = 0.27), published limitations of the study that “could table is narrower, firmer, and more number of attempts required for success- data show. shed some light” on the group’s stable, while by contrast, the ICU ful intubation,” wrote Matthew W. Semler, Further results showed that the ramped conclusions (Chest. 2017 Oct. doi: bed is wider and softer, they noted. MD, of Vanderbilt University Medical position appeared to be associated with poor 10.1016/j.chest.2017.06.002). This “may make initial positioning, “The results diverge from [oper- maintenance of positioning, and ating room] literature of the past 15 accessing the patient’s head more years that suggest that the ramped difficult.” position is the preferred intubation Nevertheless, “[this] important “Our primary outcome of lowest arterial oxygen saturation position for obese patients or those study provides ideas for further with an anticipated difficult airway.” study of optimal positioning in the is an established endpoint in ICU intubation trials, and is This may have been caused by ICU and adds valuable data to the linked to periprocedural cardiac arrest and death.” shortcomings of this study’s sparse literature on the subject in design and differences between it the ICU setting,” they concluded. and other research exploring the topic of patient positioning during James Aaron Scott, DO; Jens Matthias endotracheal intubation, they Walz, MD, FCCP; and Stephen O. Heard, Center, Nashville, Tenn., and his coau- glottic view and more difficult intubation. wrote. MD, FCCP, are in the department of thors (Chest. 2017 Oct. doi: 10.1016/j. The incidence of grade III (only epiglottis) or The study lacked a prespecified anesthesiology and perioperative medicine, chest.2017.03.061). grade IV (no visible glottis structures) views algorithm for preoxygenation and UMass Memorial Medical Center, Worcester, The ramped and sniffing positions are the were 25.4% for ramped vs. 11.5% for sniff- the operators had relatively low Mass. The authors reported no conflicts two most common patient positions used ing (P = .01), while the rate of first-attempt amounts of experience with intuba- of interest. These comments are based on during emergent intubation, according to intubation was 76.2% for ramped vs 85.4% tions. Finally, the beds used in this their editorial. investigators. The sniffing position is charac- for sniffing (P = .02). terized by supine torso, neck flexed forward, While the findings are compelling, the and head extended, while ramped position authors were forthcoming about the poten- outcomes from those of similar studies, the performed by trainees, but whether results involves elevating the torso and head. tial limitations of the study and differences researchers noted. Earlier studies included would be similar among expert opera- Some believe the ramped position may compared with earlier investigations. Nota- patients intubated by one or two senior tors remains unknown,” the investigators offer superior anatomic alignment of the bly, they said, all prior controlled trials of anesthesiologists from one center, while noted. upper airway; however, only a few obser- patient positioning during endotracheal this trial involved 30 operators across The authors reported no potential conflicts vational studies suggest it is associated with intubation were conducted in the operating multiple centers, with the average opera- of interest. One coauthor reported serving on fewer complications than the sniffing posi- room, rather than in the ICU. tor having performed 60 previous intuba- an advisory board for Avisa Pharma. tion, the authors wrote. Also, the operators’ skill levels may tions. “Thus, our findings may generalize Accordingly, they conducted a multicenter further explain differences in this study’s to settings in which airway management is [email protected] Thirty-one percent of multidrug-resistant infections were community acquired

By Amy Karon ered a plague of hospitals. Amid reports of of which none were community-acquired. Frontline Medical News increasing levels of community acquisition, After the researchers controlled for clini- the researchers studied adults admitted to a cal and demographic variables, the only AT IDWEEK 2017 202-bed regional hospital between 2013 and significant predictor of community-acquired SAN DIEGO – Thirty-one percent of multid- 2016. They defined MDROs as infections MDRO was cancer (odds ratio, 2.3; 95% rug-resistant infections were acquired from of methicillin-resistant Staphylococcus aureus confidence interval, 1.02-5.2). Surgery within the community in a prospective single- (MRSA), gram-negative bacteria resistant the previous 12 months was significantly asso- center study of a regional hospital. to more than three antimicrobial classes, ciated with hospital-acquired MDRO (OR, “Multidrug-resistant organisms have vancomycin-resistant Enterococcus (VRE), 0.16; 95% CI, 0.05-0.5). escaped the hospital,” Nicholas A. Turner, or diarrhea with a positive stool culture for Traditional risk factors for community- MD, of Duke University Medical Center, Clostridium difficile. acquired MRSA or C. difficile infection did Durham, N.C., and his associates wrote in A total of 285 patients had MDROs. not achieve statistical significance in the a poster presented at an annual scientific C. difficile (45%) and MRSA (35%) were multivariable analysis, the researchers noted. meeting on infectious diseases. “Community most common. In all, 88 (31%) MDROs “Similar to data from large tertiary care cent- acquisition of multidrug-resistant organisms were community-acquired – that is, diag- ers, our findings suggest that MDROs are [MDROs] is increasing, not just within refer- nosed within 48 hours of admission in increasingly acquired in the community ral centers but also community hospitals. patients who were not on dialysis, did setting, even at smaller regional hospitals,” Providers will need to be increasingly aware not live in a long-term care facility, and they concluded. “Further study is needed of this trend.” had not been hospitalized for more than to track the expansion of MDROs in the Infections of MDROs cause about 48 hours in the past 90 days. A total of community setting.” 2,000,000 illnesses and 23,000 deaths annu- 36% of MRSA and multidrug-resistant Dr. Turner reported having no conflicts of ally in the United States, according to the gram-negative infections were community interest. Centers for Disease Control and Preven- acquired, as were 25% of C. difficile infection. Until recently, MDROs were consid- tions. There were only 10 VRE infections, [email protected]

www.the-hospitalist.org I DECEMBER 2017 I THE HOSPITALIST 39 CLINICAL

IN THE LITERATURE ITL: Physician reviews of HM-centric research By Mel L. Anderson, MD, FACP; Kinnear Theobald, MD; Matthew Hoegh, MD; Bryan Lublin, MD, MPH; Joseph A. Simonetti, MD, MPH University of Colorado School of Medicine, Aurora

IN THIS ISSUE total of 324 unique antibiotic-associated a 1.2% absolute increase in major bleed- ADEs occurred among 298 (20%) patients ing rates, although intracranial and fatal within 90 days of initial therapy. The over- bleeding rates were similar between the two 1. Check orthostatic vital signs within 1 minute all rate of antibiotic-associated ADEs was groups. The trial was stopped early for effi- 2. Prescribe antibiotics wisely 22.9/10,000 person-days. The investiga- cacy, which may overestimate the treatment tors determined that 287 (19%) of antibi- effect. In addition, much of the benefit in 3. Rivaroxaban lowers cardiovascular risk but increases bleeding risk otic regimens were not clinically indicated, the rivaroxaban-plus- 4. Triple therapy in question and among those, there were 56 (20%) aspirin group was ADEs. The most common 30-day ADEs driven by lower rates 5. Brief preoperative score predicts postoperative complications in the elderly were gastrointestinal, renal, and hemato- of ischemic stroke. logic. The highest proportion of ADEs 6. Risk-stratification tool predicts severe hypoglycemia Rates of myocardial occurred with beta-lactams, fluoroquinolo- infarction were not 7. NSAIDs reduce spinal pain but are not “clinically important” nes, intravenous vancomycin, and trimeth- significantly different oprim-sulfamethoxazole, perhaps reflecting between the groups. 8. Cost transparency fails to affect high-cost medication utilization rates how commonly these agents are prescribed. The addition of rivar- 9. U.S. hospitalists estimate significant resources spent on defensive medicine Nearly all ADEs were considered clinically oxaban to aspirin for Dr. Theobald significant (97%). There were no deaths secondary prevention 10. Rural residents admitted for opioid overdoses increasingly are hospitalized in attributable to antibiotic-associated ADEs. should be individualized and considered urban hospitals BOTTOM LINE: Antibiotic associated ADEs in patients at high risk for ischemic stroke 11. Checklists to improve patient safety have mixed results occur in about one in five inpatients, and with low bleeding risk. about one in five antibiotic prescriptions BOTTOM LINE: Rivaroxaban plus aspirin 12. Contrast nephropathy after computed tomography may not be clinically indicated. lowers ischemic event rates in stable ather- CITATION: Tamma PD et al. Association of osclerosis compared to aspirin but increases adverse events with antibiotic use in hospi- major bleeding rates. Cost efficacy is uncer- By Mel L. Anderson, MD, FACP ates, OH at 30 seconds and 1 minute talized patients. JAMA Intern Med. 2017 tain. were associated with higher odds of dizzi- Sep 1;177(9):1308-15. CITATION: Eikelboom JW et al. Rivaroxaban Check orthostatic vital signs ness, fracture, syncope, death, and motor with or without aspirin in stable cardiovas- 1within 1 minute vehicle crashes recorded over a median Dr. Anderson is an associate program director cular disease. N Engl J Med. 2017 Oct 5. CLINICAL QUESTION: What is the relation- follow-up of 23 years. Measurements after in the internal medicine residency training doi: 10.1056/NEJMoa1709118. ship between timing of measurement of 1 minute were not reliably associated with program at the University of Colorado School postural blood pressure (BP) and adverse any adverse outcomes. of Medicine and a hospitalist at the VA Eastern Triple therapy clinical outcomes? BOTTOM LINE: Measuring OH at 30 seconds Colorado Health Care System in Denver. 4 in question BACKGROUND: Guidelines recommend and 1 minute reliably identifies patients CLINICAL QUESTION: In patients with nonval- measuring postural BP after 3 minutes at risk for associated adverse clinical By Kinnear Theobald, MD vular atrial fibrillation undergoing percuta- of standing to avoid outcomes. neous coronary intervention (PCI), is dabi- potentially false-posi- CITATION: Juraschek SP et al. Associa- Rivaroxaban lowers gatran plus a P2Y12 inhibitor safer than, and tive readings obtained tion of history of dizziness and long-term 3 cardiovascular risk but increases as efficacious as, triple therapy with warfarin? before that interval. adverse outcomes with early vs. later bleeding risk BACKGROUND: Recent studies have shown In SPRINT, ortho- orthostatic hypotension times in middle- CLINICAL QUESTION: Is rivaroxaban alone or that patients on long-term anticoagulation static hypotension aged adults. JAMA Intern Med. 2017 Sep in combination with aspirin more effective who undergo PCI can be managed on oral (OH) determined at 1;177(9):1316-23. than is aspirin alone in preventing cardi- anticoagulants and P2Y12 inhibitors with 1 minute was associ- ovascular events in patients with stable lower bleeding rates than do those who ated with higher risk Prescribe antibiotics atherosclerotic disease? receive triple therapy. of emergency depart- Dr. Anderson 2 wisely BACKGROUND: Previous studies have STUDY DESIGN: Randomized, controlled ment visits for OH CLINICAL QUESTION: What is the incidence shown that, among patients with stable trial. and syncope. Whether that finding was of antibiotic-associated adverse drug events atherosclerosis, anticoagulation with a SETTING: 414 sites in 41 countries. because of the shortened interval of meas- (ADEs) among adult inpatients? vitamin-K antagonist (VKA) plus aspirin SYNOPSIS: In 2,725 patients with nonval- urement is uncertain. BACKGROUND: Antibiotics are used widely in is superior to aspirin alone for second- vular atrial fibrillation undergoing PCI, STUDY DESIGN: Atherosclerosis Risk in the inpatient setting, although 20%-30% ary prevention but has increased rates of low-dose (110 mg, twice daily) and high- Communities Study prospective cohort. of inpatient antibiotic prescription are esti- major bleeding. dose (150 mg, twice daily) dabigatran plus SETTING: Four U.S. communities over 2 mated to be unnecessary. Data are lacking STUDY DESIGN: Randomized controlled a P2Y12 inhibitor lowered absolute bleed- decades. on the rates of associated ADEs. trial. ing risk by 11.5% and 5.5%, respectively, SYNOPSIS: In a cohort of 11,429 middle- STUDY DESIGN: Retrospective cohort study. SETTING: 602 sites in 33 countries. compared with triple therapy. Rates of aged patients, upright BP was measured SETTING: A single 1,194-bed academic SYNOPSIS: In 27,395 patients with stable thrombosis, death, and unexpected revas- every 25 seconds over a 5-minute inter- tertiary medical center. atherosclerotic disease, the addition of cularization as a composite endpoint were val after participants had been supine for SYNOPSIS: Of the 5,579 patients admit- 2.5 mg rivaroxaban twice daily to aspirin noninferior to triple therapy for both dabi- 20 minutes. About 2-3 seconds elapsed ted to four inpatient medicine services therapy reduced the rates of cardiovascu- gatran doses studied. In patients on dabi- between the end of one BP measurement between September 2013 and June 2014, lar death, stroke, or nonfatal MI, at the gatran for atrial fibrillation, it is reasonable and the initiation of the next. OH was 1,488 (27%) received antibiotics for at cost of increased major bleeding rates. The to continue dabigatran and add a single defined as a 20–mm Hg drop in systolic least 24 hours. Patients were followed authors found a 1.3% absolute risk reduc- P2Y12 inhibitor (clopidogrel or ticagre- BP. After researchers adjusted for covari- through admission and out to 90 days. A tion in recurrent cardiovascular events, but CONTINUED ON PAGE 42

40 THE HOSPITALIST I DECEMBER 2017 I www.the-hospitalist.org Invasive fungal infection my UNDERSTANDING (IFI) can have a profound invasive fungal infection

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References: 1. Pappas PG et al. Clin Infect Dis. 2016;62(4):e1-e50. 2. Patterson TF et al. Clin Infect Dis. 2016;63(4):e1-e60.

HOSP_41.indd 1 11/16/2017 8:22:33 PM IN THE LITERATURE I continued from page 40

PEDIATRIC HM LITERATURE I By Sam Stubble eld, MD Optimal rate of flow for high-flow nasal cannula in young children

CLINICAL QUESTION: Is there an difference between maximum and flow rates of 0.5, 1, 1.5, and 2 L/ the highest level of HFNC patients optimal rate of flow for high- minimum esophageal pressures by kg per minute to a maximum of 30 could tolerate without worsening flow nasal cannula in respira- the respiratory rate.1 An increas- L/min. Following the trials, patients agitation or air leak. There was no tory distress? ing PRP indicates increasing effort remained on HFNC as per usual difference seen between the two Dr. Stubblefield is a of breathing. The authors chose care with twice-daily PRP measure- HFNC systems in the study. The pediatric hospitalist at BACKGROUND: High-flow nasal systems from Fisher & Paykel and ments until weaned off HFNC. authors did not report the fraction Nemours/Alfred I. duPont cannula (HFNC) has been Vapotherm for their testing. A dose-dependent relationship of inspired oxygen settings used, Hospital for Children increasingly used to treat chil- existed between flow and change the size of HFNC cannulas, or how in Wilmington, Del., dren with moderate to severe STUDY DESIGN: Single-center in PRP, with the greatest reduction PRP changed over several days as and clinical assistant bronchiolitis, both in inten- prospective observational trial. in PRP at 2 L/kg per minute flow (P HFNC was weaned. professor of pediatrics sive care unit settings and on less than .001) and a slightly smaller at Jefferson Medical inpatient wards. Studies have SETTING: 24-bed pediatric inten- but similar reduction in PRP at 1.5 BOTTOM LINE: The optimal College in Philadelphia. Patientsshown it may older allow children than 65 yearssive care have unit in lower a 347-bed 30-day urban mortalityL/kg per minute. When the subjects HFNC rate to decrease effort of with bronchiolitis to avoid free-standing children’s hospital. were stratified by weight, this effect breathing for children less than 3 andICU admissionreadmission and intuba- rates when receiving inpatient carewas not statistically significant for years old is between 1.5 and 2 L/ tion. In preterm infants it has SYNOPSIS: A single center patients heavier than 8 kg (P = .38), kg/min with the greatest improve- frombeen shown a female to decrease internist, work comparedrecruited patients with aged care37 weeks by a withmale all significant changes being in ment expected in children under of breathing. No prior stud- corrected gestational age to 3 patients less than 8 kg (P less than 5 kg. internist.ies, however, have examined years who were admitted to the .001) with a median drop in PRP optimizing the rate of flow for ICU with respiratory distress. of 25%. Further examination of CITATION: Weiler T et al . The individual patients, and consid- Fifty-four patients met inclusion age and weight revealed that the Relationship Between High Flow erable heterogeneity exists in criteria and 21 were enrolled and greatest reduction in PRP was in Nasal Cannula Flow Rate and choosing initial HFNC flow completed the study. Prior data the lightest patients (less than 5 kg). Effort of Breathing in Chil- rates. suggested a sample size of 20 Given the similarity in drop in dren. The Journal of Pediatrics. Reliably measuring effort of would be sufficient to identify a PRP at 1.5 L/kg per minute and October 2017. doi: 10.1016/j. breathing has proved challeng- clinically significant effect size. 2 L/kg per minute, the authors jpeds.2017.06.006. ing. Placing a manometer in Median age was 6 months. suggest this flow rate yields a the esophagus allows measure- Thirteen patients had bronchioli- plateau effect and minimal further REFERENCE ment of the pressure-rate prod- tis, three had pneumonia, and five improvement would be seen with 1. Argent AC, Newth CJL, Klein M. The mechan- ics of breathing in children with acute severe uct (PRP), a previously validated had other respiratory illnesses. Each increasing flow rates. A rate of 2 croup. Intensive Care Med. 2008;34(2):324-32. measure of effort of breathing patient received HFNC delivered L/kg per minute was chosen as a doi: 10.1007/s00134-007-0910-x. computed by multiplying the by both systems in sequence with maximum a priori as it was judged

lor) but not aspirin after PCI. In patients at elderly. This population is at a higher risk More specifically, preexisting difficulties cohort); Veterans Affairs Diabetes Epidemi- high risk for bleeding complications, it may for postsurgical complications. Previous with activities of daily living, anticipated ology Cohort and Group Health Coopera- be reasonable to dose reduce the dabigatran research into preoperative risk assessment self-care difficulty, a Charlson Comorbid- tive (external validation cohorts). from 150 mg twice daily to 110 mg twice relied on geriatricians, of whom there is a ity score of 2 or greater, male sex, or higher SYNOPSIS: Through EHR data, 206,435 daily before starting antiplatelet therapy, national shortage. surgical relative value units were all inde- eligible patients with T2D were randomly although the study was underpowered to STUDY DESIGN: Prospective cohort study. pendently associated with postoperative split into derivation (80%) and internal examine this. SETTING: Preoperative surgery clinics at the complications. validation (20%) samples. EHR data were BOTTOM LINE: In patients with atrial fibril- University of Michigan Health System. BOTTOM LINE: Elderly patients at an reviewed for preselected clinical risk factors lation undergoing PCI, dabigatran plus SYNOPSIS: A total of increased risk of postoperative complica- for hypoglycemia with a primary outcome clopidogrel or ticagrelor had lower bleed- 736 elderly patients tions can be identified by nonphysician of ED visit or hospital admission with a ing rates and was noninferior with respect had a preoperative staff using the VESPA preoperative assess- primary diagnosis of hypoglycemia over to the risk of thromboembolic events when Vulnerable Elders ment. the ensuing year. A predictive tool was compared with triple therapy with warfa- Surgical Pathways and CITATION: Min L et al. Estimating risk of built based on six variables: prior hypogly- rin. Outcomes Assessment postsurgical general and geriatric complica- cemia episodes, number of ED encounters CITATION: Cannon CP et al. Dual antithrom- (VESPA) adminis- tions using the VESPA preoperative tool. for any reason in the prior year, insulin botic therapy with dabigatran after PCI in tered by a surgical JAMA Surg. 2017 Aug 2. doi: 10.1001/ use, sulfonylurea use, presence of severe or atrial fibrillation. N Engl J Med. 2017 Oct physician assistant jamasurg.2017.2635. end-stage kidney disease, and age. Predicted 19. doi: 10.1056/NEJMoa1708454. in clinic. VESPA Dr. Hoegh 12-month risk was categorized as high assessed activities Risk-strati cation tool predicts (greater than 5%), intermediate (1%-5%) Dr. Theobald is a hospitalist at the University of of daily living, history of falling or gait 6 severe hypoglycemia or low (less than 1%). In the internal valida- Colorado School of Medicine. impairment, and depressive symptoms. CLINICAL QUESTION: Can a clinical tool be tion sample, 2.0%, 10.7%, and 87.3% of Patients underwent a Mini-Cog examina- developed to predict severe hypoglycemia patients were categorized as high, interme- By Matthew Hoegh, MD tion and a Timed Up and Go assessment. in at-risk patients with type 2 diabetes diate, and low risk, respectively. Observed Patients were asked whether they expected (T2D)? 12-month hypoglycemia-related health Brief preoperative score predicts they could manage themselves alone after BACKGROUND: Severe hypoglycemia caused care utilization rates were 6.7%, 1.4%, and 5 postoperative complications in the discharge. One in seven patients reported by glucose-lowering medications is a known 0.2%, respectively. The external validation elderly difficulty with one or more of the activities public health and patient safety issue. Iden- cohorts performed similarly. CLINICAL QUESTION: Can a geriatric assess- of daily living and one in three stated they tifying patients with T2D at risk of severe BOTTOM LINE: A simple tool using readily ment scale, performed by nonphysician would be unable to manage postoperative hypoglycemia might facilitate interventions available data can be used to estimate the surgical staff, be used to predict postopera- self-care alone. Overall, 25.3% of patients to offset that risk. 12-month risk of severe hypoglycemia in tive complications in the elderly? had geriatric or surgical complications. STUDY DESIGN: Prospective cohort. patients with T2D. BACKGROUND: Elective operations have The VESPA score predicted postoperative SETTING: Kaiser Permanente Northern Cali- CITATION: Karter AJ et al. Development become increasingly more common in the complications (area under the curve, 0.76). fornia (derivation and internal validation and validation of a tool to identify patients

42 THE HOSPITALIST I DECEMBER 2017 I www.the-hospitalist.org with type 2 diabetes at high risk of hypo- reduction than placebo in the immediate care expenditures and may be avoidable SHORT TAKES glycemia-related emergency department or (number needed to treat, 5; 95% confi- when low-cost alternatives are available. hospital use. JAMA Intern Med. 2017 Oct dence interval, 4-6) and short (NNT, STUDY DESIGN: Retrospective, observational 1;177(10):1461-70. 6; 95% CI, 4-10) range. However, this analysis of a quality improvement project. Pacing in syncope for effect did not meet the specified 10-point SETTING: Single center, 1,145-bed, tertiary- select patients only NSAIDs reduce spinal pain but are difference to support “clinical impor- care academic medical center. The 2017 ACC/AHA/HRD 7 not “clinically important” tance,” despite having favorable numbers SYNOPSIS: Nine medications were chosen by guideline for syncope evalu- CLINICAL QUESTION: Are nonsteroidal anti- needed to treat. Limited corresponding committee to be targeted for intervention: ation and management inflammatory drugs effective at reducing safety analysis did not find significant intravenous voriconazole, IV levetiracetam, concludes that the evidence neck and low back pain? adverse event rate differences other than IV levothyroxine, IV does not yet support the use BACKGROUND: Although neck and low back increased reporting of gastrointestinal linezolid, IV eculi- of pacing for reflex-mediated pain are leading causes of pain and disabil- symptoms. zumab, IV pantopra- except among those with both ity, there is no consensus first-line phar- BOTTOM LINE: NSAIDs reduce spinal pain, zole, IV calcitonin, recurrent vasovagal syncope macologic therapy for treatment. Recent compared with placebo, with low numbers inhaled ribavirin, and and asystole documented by research has pointed to acetaminophen needed to treat, but nevertheless were not IV mycophenolate. implantable loop recorder. as being ineffective, which – in combina- determined to have a “clinically important” The costs for these tion with increased awareness of opioid effect. nine medications plus CITATION: Varosy P et al. Pacing dependency and adverse risks – could lead CITATION: Machado GC et al. Nonsteroidal lower-cost alterna- as a treatment for reflex-medi- to greater use of NSAIDs. anti-inflammatory drugs for spinal pain: A tives were displayed Dr. Lublin ated (vasovagal, situational, or STUDY DESIGN: Systematic review and meta- systematic review and meta-analysis. Ann for providers in the carotid sinus hypersensitivity) analysis. Rheum Dis. 2017 Jul;76(7):1269-78. order entry system after about 2 years of syncope: A systematic review SETTING: Randomized controlled trials. baseline data had been collected. There was for the 2017 ACC/AHA/HRS SYNOPSIS: Researchers used MEDLINE, Dr. Hoegh is a hospitalist at the University of no change in the number of orders or order- guideline for the evaluation and EMBASE, CINAHL, CENTRAL, Colorado School of Medicine. ing trends for eight of the nine high-cost management of patients with and LILACS to select 35 randomized, medications after the intervention. Only syncope. J Am Coll Cardiol. placebo-controlled trials evaluating By Bryan Lublin, MD, MPH ribavirin was ordered less after cost messag- 2017 Aug 1;20(5):664-79. the impact of NSAIDs on reducing ing was implemented (16.3 fewer orders per spinal pain and disability from a total Cost transparency fails to affect 10,000 patient-days). Lower IV pantopra- of 302 full-text articles. Trial data were 8 high-cost medication utilization zole use (73% reduction), correlated with these nine high-cost medications. pooled based on follow-up time and rates a national shortage unrelated to the study CITATION: Conway SJ et al. Impact of outcomes. Pain and disability outcomes CLINICAL QUESTION: Does cost messaging at intervention, a potential confounder. Data displaying inpatient pharmaceutical costs were converted to a 100-point scale the time of ordering reduce prescriber use on dosing frequency and duration were not at the time of order entry: Lessons from with a 10-point difference between of high-cost medications? collected. a tertiary care center. J Hosp Med. 2017 groups defined as “clinically important.” BACKGROUND: Overprescribing expensive BOTTOM LINE: Displaying medication costs Aug;12(8):639-45. NSAIDs were found to offer greater pain medications contributes to inpatient health and alternatives did not alter the use of CONTINUED ON FOLLOWING PAGE Coming January 2018

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www.the-hospitalist.org I DECEMBER 2017 I THE HOSPITALIST 43 IN THE LITERATURE I continued from previous page

U.S. hospitalists estimate between liability experience and perception trends in opioid overdose hospitalizations als are hospitalized for opioid overdose in 9 signicant resources spent on of defensive medicine spending. Differ- by rural status have not been described. urban facilities. These patients may have defensive medicine ences between academic and community STUDY DESIGN: Time distinct discharge needs. CLINICAL QUESTION: What percent of inpa- settings were not addressed. Because only trend (2007-2014) CITATION: Mosher H et al. Trends in hospi- tient health care spending by hospitalists 30% of practicing hospitalists are members and cross-sectional talization for opioid overdose among rural can be attributed to defensive medicine? of SHM, it may be difficult to generalize analysis (2012-2014). compared to urban residents of the United BACKGROUND: Defensive medicine contrib- these findings. SETTING: Nationally States, 2007-2014. J Hosp Med. 2017. doi: utes an estimated $45 billion to annual BOTTOM LINE: Hospitalists perceive that representative sample 10.12788/jhm.2793. U.S. health care expenditures. The preva- defensive medicine is a major contributor of U.S. hospital lence of defensive medicine among hospi- to inpatient health care expenditures. discharges. Checklists to improve patient talists is unknown. CITATION: Saint S et al. Perception of SYNOPSIS: Using 11 safety have mixed results STUDY DESIGN: Survey of U.S.-based hospi- resources spent on defensive medicine weighted data from Dr. Simonetti CLINICAL QUESTION: Do checklists improve talists. and history of being sued among hospi- the National Inpa- patient safety among hospitalized patients? SETTING: National survey sent to 1,753 talists: Results from a national survey. J tient Sample and the American Commu- BACKGROUND: Systematic reviews of hospitalists from all 50 states identified Hosp Med. 2017 Aug 23. doi: 10.12788/ nity Survey, the authors found that 43,935 nonrandomized studies suggest check- through the Society of Hospital Medicine jhm.2800. individuals were hospitalized for opioid lists may reduce adverse events and medi- database of members and meeting attend- overdose in the United States in 2007, cal errors. No study has systematically ees. Dr. Lublin is a hospitalist at the University of increasing to 71,280 in 2014. A total of reviewed randomized trials or summarized SYNOPSIS: The survey contained two Colorado School of Medicine. 99% of urban and 37% of rural residents the quality of evidence on this topic. primary topics: an estimation of defensive were admitted to urban hospitals. Hospi- STUDY DESIGN: Systematic review of rand- spending and liability history. The hospi- By Joseph A. Simonetti, MD, talization rates for prescription opioid over- omized controlled trials (RCTs) with talists, who had an average of 11 years in MPH doses were higher among rural residents pooled estimates of 30-day mortality. practice, completed 1,020 surveys. Partic- and increased among rural and urban resi- SETTING: RCTs reporting inpatient safety ipants estimated that defensive medicine Rural residents admitted for dents until 2011 before declining among outcomes. accounted for 37.5% of all health care 10 opioid overdoses increasingly rural residents during 2012-2014. Hospi- SYNOPSIS: A search among four databases costs. Decreased estimate rates were seen are hospitalized in urban hospitals talization rates for prescription opioid over- from inception through 2016 yielded among VA hospitalists (5.5% less), male CLINICAL QUESTION: Is there an association doses increased among all groups before nine studies meeting inclusion criteria. respondents (36.4% vs. 39.4% for female), between rurality and trends and character- they declined among large urban popula- Checklists included tools for daily round- non-Hispanic white respondents (32.5% istics of hospitalizations for opioid over- tion residents after 2011, declined among ing, discharge planning, patient trans- vs. 44.7% for other) and having more dose? rural residents after 2012, and contin- fer, surgical safety and infection control years in practice (decrease of 3% for every BACKGROUND: Hospitalization for an opioid ued to rise among small urban residents. procedures, pharmaceutical prescribing, 10 years in practice). One in four respond- overdose is an opportunity for intervention, Hospitalization rates for heroin overdose and pain control. Three studies examined ents reported being sued at least once, and patients may have different discharge increased across all years in all groups and 30-day mortality, three studied length of with higher risk seen in those with greater needs depending on their rurality. Differ- were higher among urban as compared to stay, and two reported checklist compli- years in practice. There was no association ences in patient characteristics or overall rural residents. ance. Five reported patient outcomes and BOTTOM LINE: Opioid overdose hospitaliza- five reported provider-level outcomes tion is associated with patient rurality and related to patient safety. Findings regard- a significant proportion of rural individu- ing the effectiveness of checklists across

SHORT TAKES

Postoperative opioids Poor food intake and chills Connecting practices to often underutilized predict true bacteremia Between 67% and 92% of in hospitalized patients patients report postoperative Observational study showing EMERGING TRENDS. opioid oversupply, defined as that poor food consumption had filled but unused opioid prescrip- a sensitivity of 93.7% and shak- We’re taking the mal out of malpractice insurance. In an ever-evolving healthcare environment, we tions or unfilled opioid prescrip- ing chills a specificity of 95.1% stay on top of the latest risks, regulations, and tions. Half of the filled prescrip- in diagnosing true bacteremia advancements. From digital health innovations to tions were unused, with the based on blood culture results. new models of care and everything in between, majority reporting that the narcot- we keep you covered. And it’s more than a trend. ics were not stored in locked CITATION: Komatsu T et al. A simple It’s our vision for delivering malpractice insurance without the mal. Join us at thedoctors.com containers. algorithm for predicting bacteremia using food consumption and shak- CITATION: Bicket MC et al. ing chills: a prospective observa- Prescription opioid analgesics tional study. J Hosp Med. 2017 commonly unused after surgery: Jul;12(7),510-5. A systematic review. JAMA Surg. 2017 Aug 2. doi: 10.1001/jama- Lower readmission surg.2017.0831 rates do not lead to increased postdischarge 5-hour protocol for contrast mortality at 30 days allergy safe and effective Post–Affordable Care Act reduc- Observational study show- tions in 30-day hospital risk- ing a 5-hour IV steroid protocol adjusted readmission rates was noninferior to a traditional for heart failure, acute MI, and 13-hour oral premedication regi- pneumonia among Medicare men in patients at high risk for IV beneficiaries did not increase contrast reactions. but were weakly associated with decreased 30-day post–hospital CITATION: Mervak BM et al. Intra- discharge risk-adjusted mortality. venous corticosteroid premedication administered 5 hours CITATION: Dharmarajan K et al. before CT, compared with a Association of changing hospital traditional 13-hour oral regimen. readmission rates with mortal- Radiology. 2017 Nov;285(2): ity rates after hospital discharge. 425-33. JAMA. 2017Jul 18;318(3):270-8.

44 THE HOSPITALIST I DECEMBER 2017 I www.the-hospitalist.org studies were mixed. A random-effects checklists on inpatient safety outcomes: A assessing differences in AKI, new RRT, multiple settings (for example, ICU, emer- model using pooled data from the three systematic review of randomized controlled or mortality among adults who received gency department), and the baseline char- studies assessing 30-day mortality showed trials. J Hosp Med. 2017 Aug;12:675-82. contrast-enhanced CT, compared with acteristics of included patients were highly lower mortality associated with checklist those receiving noncontrast CT. variable. use (odds ratio, 0.6, 95% confidence Contrast nephropathy after SYNOPSIS: A search among six databases and BOTTOM LINE: This meta-analysis observed interval, 0.41-0.89; P = .01). The meth- 12 computed tomography Google Scholar from inception through no difference in adverse events between odologic quality of studies was assessed CLINICAL QUESTION: Do rates of acute kidney 2016 yielded 28 observational studies patients receiving contrast-enhanced CT as moderate. The review included studies injury (AKI), renal replacement therapy meeting inclusion criteria that included versus those receiving noncontrast CT but with substantial heterogeneity in check- (RRT), or mortality differ between adults 107,335 participants. Twenty-six assessed should be interpreted with caution given lists employed and outcomes assessed. receiving contrast-enhanced computed AKI, 13 assessed need for RRT, and 9 the observational nature of the studies and Though included studies were supposed tomography (CT) versus those receiving assessed all-cause mortality. Compared differing characteristics of the included to have assessed patient outcomes and not noncontrast CT? with noncontrast CT, contrast-enhanced patients and study settings. the processes of care, several studies cited BACKGROUND: Published estimates regard- CT was not significantly associated with CITATION: Aycock RD et al. Acute did not report such outcomes. ing the risk of postcontrast complications AKI (odds ratio, 0.94; 95% confidence kidney injury after computed tomogra- BOTTOM LINE: Evidence regarding the effec- are highly variable and recent data show interval, 0.83-1.07), RRT (OR, 0.83; 95% phy: a meta-analysis. Ann Emerg Med. tiveness of clinical checklists on patient that the risk of postcontrast AKI may be CI 0.59-1.16), or all-cause mortality (OR, 2017 Aug 12. doi: 10.1016/j.anne- safety outcomes is mixed, and there is lower than previously suggested. 1.0; 95% CI 0.73-1.36). The overall risk mergmed.2017.06.041 substantial heterogeneity in the types of STUDY DESIGN: Systematic review and meta- of bias ranged from low to serious among checklists employed and outcomes assessed. analysis. the included studies. Studies were obser- Dr. Simonetti is a hospitalist at the University of CITATION: Boyd JM et al. The impact of SETTING: Noninterventional studies vational in nature, they were conducted in Colorado School of Medicine.

NEWS I Clinical developments, health care policy, and regulations Opioid management protocol lowered trauma patient pain medication use A targeted pain management protocol for trauma patients addressed the problem of overprescribing of opioids

By Eli Zimmerman “By having a comprehen- MD,FACS, medical director of the trauma Frontline Medical News ICU at Vanderbilt University, Nashville, sive pain management pro- Tenn., acknowledged the importance of AT THE AAST ANNUAL MEETING PMPs and the work investigators presented. BALTIMORE – A pain management protocol tocol, we can reduce the “I would consider this the next genera- implemented in a trauma service reduced tion of ERAS [enhanced recovery after opioid intake in trauma patients while amount of pain medications surgery], or ERAT [enhanced recovery after improving patient satisfaction, according trauma] in pain perception modification,” to a retrospective study. we prescribe for outpatient said Dr. Guillamondegui. “Dr. Gross and The opioid epidemic continues to grow use, from discharge from the multidisciplinary group at Wake Forest every day, partly as a result of irrespon- have provided compelling evidence to help sible overprescribing of opioid medica- the trauma service.” alleviate [the opioid epidemic].” tion, according to Jessica Gross, MB In a question-and-answer session follow- BAO BCh, FACS, a trauma surgeon from ing the presentation, attendees voiced Wake Forest (N.C.) Baptist Health at the concern over how a PMP would be used American Association for the Surgery of gram equivalents (MME), compared with among patients who are more familiar with Trauma annual meeting. Dr. Gross and 2,421 MME prior to the protocol (P less hospital systems, in particular concerning her colleagues developed a pain manage- than .0001). self-reported pain levels. ment protocol (PMP) to provide adequate After the protocol was implemented, Dr. “Most of us employed at acute care cent- pain control while using fewer opioids in Gross and her colleagues found the number ers are not working in utopia. Many of our the postdischarge setting. They tested their of patients prescribed a refill dropped from patients are heroin addicts, are very bright, PMP through a retrospective chart review of 39.7% to 28.1%, with the size of those and know how to identify 10 on those silly 498 patients admitted to the trauma service refills dropping from 1,032 MME to 213 smiley faces so that they get more medicine,” between January 2015 and December 2016, MME on average. said Charles Lucas, MD, FACS, professor of half of which were admitted before the PMP “By having a comprehensive pain surgeon at Wayne State University, Detroit. was initiated and half of which were admit- management protocol, we can reduce the Dr. Lucas also pointed out that, even when ted afterward. amount of pain medications we prescribe patients report false levels of pain, doctors The PMP involved a stepped approach for outpatient use, from discharge from still are required to put it into the electronic to treating pain, with acetaminophen or the trauma service,” said Dr. Gross. “Addi- medical record for fear of repercussions, ibuprofen as needed for mild pain, one tionally, we have shown that, by having a In response, Dr. Gross said doctors on the 5-mg tablet of oxycodone/acetaminophen protocol in place, we not only decreased the floor reviewed patients to make sure they every 6 hours for moderate pain, two tablets number of refills we were providing, but were receiving all doses of pain medications. for severe pain, and 50-100 mg of tramadol also the amount of pain medications that If doctors felt the patient’s pain regimen every 6 hours for breakthrough pain. was prescribed within these refills.” was adequate, despite the patient reporting Counseling services for patients who were Through a Press Ganey survey analysis otherwise, no changes were made. found to be in danger of substance use were of patients during the month before and Certain limitations include not being provided in the hospital, and at discharge, the month after the PMP implementation, able to confirm whether patients received patients received a weaning plan for their investigators found a significant increase prescription medication elsewhere, nor any medication, according to Dr. Gross. in patient satisfaction and overall pain concrete data on patient satisfaction after If the short-acting medications were management, according to Dr. Gross, discharge other than an inference based on found to be inadequate to control pain, In addition, the main trauma floor where fewer refills and lower refill MME. patients were given slow-release pain medi- the PMP was implemented was recognized Investigators reported no relevant finan- cation as needed. for the most improvement in overall hospi- cial disclosures. Average total medication, including at tal rating and pain management, compared discharge and for refills, prescribed after with the previous year. [email protected] PMP initiation was 1,242 morphine milli- Discussant Oscar Guillamondegui On Twitter @eaztweets

www.the-hospitalist.org I DECEMBER 2017 I THE HOSPITALIST 45 NEWS I Clinical developments, health care policy, and regulations Abnormal potassium plus suspected ACS spell trouble

By Bruce Jancin admission serum potassium of 3.5 to less Frontline Medical News than 4.0 mmol/L – and patients with an admission serum potassium above or below AT THE ESC CONGRESS 2017 those cutoffs. BARCELONA – A serum potassium level of In a multivariate logistic regression analy- at least 5.0 mmol/L or 3.5 mmol/L or less sis adjusted for 24 potential confounders, at admission for suspected acute coronary including demographics, presentation char- syndrome is a red flag for increased risk of acteristics, main diagnosis, comorbid condi- in-hospital mortality and cardiac arrest, tions, medications on admission, and esti- according to a Swedish study of nearly mated glomerular filtration rate, patients 33,000 consecutive patients. with a serum potassium of 5.0 to less than That’s true even if, as so often ultimately 5.5 mmol/L were at 1.8-fold increased proves to be the case, the patient turns out risk of in-hospital mortality. Those with a not to have ACS, Jonas Faxén, MD, of the potassium of 5.5 mmol/L or greater were at Karolinska Institute, Stockholm, reported 2.3-fold increased risk. at the annual congress of the European In contrast, a low rather than a high Society of Cardiology. serum potassium was an independent risk “This study highlights that, if you have a factor cardiac arrest. An admission potas- Jonas Faxén, MD, of the Karolinska Institute in Stockholm patient in the emergency department with sium of 3.0 to less than 3.5 mmol/L carried a possible ACS and potassium imbalance, a 1.8-fold increased risk of in-hospital you should really be cautious,” Dr. Faxén cardiac arrest, while a potassium of less than said. 3.0 was associated with a 2.7-fold increased “This study highlights that, if you have a patient in the He reported on 32,955 consecutive risk. emergency department with a possible ACS and potas- patients admitted to Stockholm County A serum potassium below 3.0 mmol/L hospitals for suspected ACS during at admission also was associated with a sium imbalance, you should really be cautious.” 2006-2011 and thereby enrolled in the 1.7-fold increased risk of new-onset atrial SWEDEHEART (Swedish Web System fibrillation. for Enhancement and Development of These elevated risks of bad outcomes Evidence-Based Care in Heart Disease didn’t differ significantly between patients nary care we had to get their potassium to arrest can often be resuscitated,” Dr. Walker Evaluated According to Recommended with ST-elevation MI, non-STEMI ACS, 4.5-5.0 mmol/L. I think you might want to commented. Therapies) registry. and those whose final diagnosis was not change that advice now.” Dr. Faxén reported having no financial Overall in-hospital mortality was 2.7%. ACS, Dr. Faxén noted. “The implication would be that, if conflicts regarding his study, which was In-hospital cardiac arrest occurred in 1.5% Session cochair David W. Walker, you intervene quickly in a patient with funded by the Swedish Heart and Lung of patients. New-onset atrial fibrillation MD, medical director of the East Sussex an abnormal potassium level, you might Foundation and the Stockholm County occurred in 2.4% of patients. These key (England) Healthcare NHS Trust, observed, make a difference. Clearly, a potassium Council. outcomes were compared between the refer- “When I was a junior doctor I was always that’s too high is much worse than too ence group – defined as patients with an taught that when patients came onto coro- low, since patients with in-hospital cardiac [email protected] LVAD use soars in elderly Americans

By Mitchel L. Zoler this, in-hospital mortality rates of elderly Frontline Medical News patients receiving an LVAD plummeted, dropping from 61% of elderly LVAD recip- AT THE HFSA ANNUAL ients in 2003 to 18% in 2014. During the SCIENTIFIC MEETING same time, the percentage of elderly patients DALLAS – The percentage of left ventricu- with a Charlson Comorbidity Index score lar assist devices placed in U.S. heart fail- greater than four doubled from 33% in 2003 ure patients at least 75 years of age jumped to 66% in 2014, said Dr. Rali, a cardiologist sharply during 2003-2014, and concurrently at the University of Kansas Medical Center the short-term survival of these patients in Kansas City. improved dramatically, according to data “If the Charlson Comorbidity Index score collected by the National Inpatient Sample. is increasing but in-hospital mortality is During the 12-year period examined, decreasing, then increased LVAD use is not a the percentage of left-ventricular assist bad trend,” Dr. Rali said in an interview. He devices (LVADs) placed in U.S. heart fail- hopes that future analysis of longitudinal data ure patients aged 75 years and older rose from patients could identify clinical factors from 3% of all LVADs in 2003 to 11% that link with better patient survival and help in 2014, Aniket S. Rali, MD, said at the target LVAD placement to the patients who annual scientific meeting of the Heart Fail- stand to gain the most benefit. ure Society of America. “We may be able to give these elderly In actual numbers, LVAD placement into patients not just longer life but improved qual- elderly patients jumped from 23 in 2003 to ity of life” by a more informed targeting of 405 in 2014, a greater than 17-fold increase. LVADs, he suggested. “I think these numbers During the same period, total U.S. LVAD use will help convince people that all is not lost,” Aniket S. Rali, MD, of the University of Kansas Medical Center, Kansas City rose from 726 placed in 2003 to 3,855 placed he noted, for elderly heart failure patients in 2014, about a fivefold increase. who receive an LVAD as destination therapy. men at least 75 years old rising from 1.4/1,000 ied was 77.6 years among a total of 2,090 The U.S. national numbers also showed Patients at least 75 years old are not eligible for patients in 2003 to 2.78/1,000 patients in recipients. For all 21,323 U.S. LVAD recipi- that, throughout the period studied, elderly heart transplantation, so when these patients 2014. In contrast, among women these rates ents during 2003-2014 the average age was U.S. patients who received an LVAD were receive an LVAD it is, by definition, destina- rose from 0.8/1,000 patients in 2003 to 51.5 years old. increasingly sicker, with steadily increasing tion therapy. 1.36/1,000 patients in 2014. numbers of patients with a Charlson Comor- The data also showed a marked sex dispar- The average age for elderly U.S. LVAD [email protected] bidity Index score of four or greater. Despite ity in LVAD use, with LVAD placement in recipients for the entire 12-year period stud- On Twitter @mitchelzoler

46 THE HOSPITALIST I DECEMBER 2017 I www.the-hospitalist.org Make your next smart move. Visit www.shmcareercenter.org

PHYSICIAN OPPORTUNITIES IN Network Medical Director for 7 Hospital System in PA/NJ The Medical Director, Hospitalist Service, is responsible for providing on-site clinical leadership and management for the Network. This individual will serve as the clinical TEXAS lead and will work closely with physicians, Site Medical Directors, AP leadership and Staff to assure consistent high quality in keeping with the goals of the organization and the and thousands of communities nationwide group. Must have three to five years’ experience in Hospital Medicine and be board certified; leadership experience strongly preferred. Excellent compensation and benefit package. SLUHN is a non-profit network comprised of more than 450 physicians, 200 advanced practitioners and 7 hospitals, providing care in eastern Pennsylvania and western NJ. St. Luke’s currently has more than 180 physicians enrolled in internship, residency and fellowship programs and is a regional campus for the Temple/St. Luke’s School of JOIN OUR HOSPITAL MEDICINE TEAM Medicine. Visit www.slhn.org. Our campuses offer easy access to major cities like NYC Hospitalist opportunities in: and Philadelphia. Cost of living is low coupled with minimal Methodist Hospital of San Antonio, San Antonio, TX congestion; choose among a variety of charming urban, semi-urban and rural communities your family will enjoy Methodist Stone Oak Hospital, San Antonio, TX calling home. For more information visit Methodist Specialty and Transplant Hospital, San Antonio, TX www.discoverlehighvalley.com Metropolitan Methodist Hospital, San Antonio, TX Please email your CV to Drea Rosko at [email protected] Methodist Texan Hospital, San Antonio, TX Northeast Methodist Hospital, Live Oak, TX

Beneﬁts ¢ Medical Director Stipend ¢ Malpractice Insurance Join the largest physician-led and governed medical group in Illinois! ¢ Leadership Development Opportunities IMMEDIATE OPENINGS-Advocate Medical Group (AMG), a part of ¢ Attractive Practice Locations Nationwide Advocate Health Care, is actively recruiting HOSPITALISTS for growing teams across metro Chicago. ¢ Flexible Employment Options •Flexible 7 on7 off scheduling ¢ Equitable Scheduling • Manageable daily census ¢ Exceptional Quality of Practice •Established, stable program with 90+ providers •First-rate specialist support •Comprehensive benefits, relocation & CME allowance

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YOUR AD HERE! MUSTAFA SARDINI, M.D. Sunnyvale, TX Heather Gonroski Linda Wilson 973.290.8259 or 973.290.8243 [email protected] [email protected]

Physicians, yoyou’reu’re just one clclickick aawayway ffromrom youryour nextnext job with the new SHM Career Center You’ve never had a more powerful ally in making your next career move. The new SHM Career Center is designed for busy doctors. Now you can: • Create job alerts • Save your jobs Find your next job today. • Quickly search for jobs on your smartphone — works seamlessly! Visit www.shmcareers.org Create a candidate pro le and get matched to your ideal job

To learn more, visit www.the-hospitalist.org and click “Advertise”or contact Heather Gonroski • 973-290-8259 • [email protected] or Linda Wilson • 973-290-8243 • [email protected]

www.the-hospitalist.org I DECEMBER 2017 I THE HOSPITALIST 47 Make your next smart move. Visit www.shmcareercenter.org

HOSPITALIST ,ŽƐƉŝƚĂůŝƐƚͲůĞǀĞůĂŶĚ

The Division of Internal Medicine at Penn State Hershey Medical Center, The Pennsylvania State University College of Medicine, is Leaders in Hospital Medicine since 1998 accepting applications for HOSPITALIST positions. Successful candidates will hold a faculty appointment to Penn State College of Medicine and will be responsible for the care in patients at Penn State Hershey Medical Center. Individuals should have experience www.theMHG.com in hospital medicine and be comfortable managing patients in a subacute care setting. Hospitalists will be part of the post-acute 440.542.5000 care program and will work in collaboration with advanced practice clinicians, residents, and staff. In addition, the candidate will supervise physicians-in-training, both graduate and undergraduate level, as well as participate in other educational initiatives. The 2SSRUWXQLWLHVPLQXWHV candidate will be encouraged to develop quality improvement projects in transitions of care and other scholarly pursuits around caring IURPVSRUWVWKHDWUHV for this population. This opportunity has potential for growth into a leadership role as a medical director and/or other leadership PXVHXPVPXVLFDQG roles. JUHDWUHVWDXUDQWV Competitive salary and benefits among highly qualified, friendly colleagues foster networking opportunities. Relocation assistance, CME funds, Penn State University tuition discount for employees and dependents, LTD and Life insurance, and so much more! ^ĞŶĚsƚŽ: Known for home of the Hershey chocolate bar, Hershey, PA is rich in history and offers a diverse culture. Our local neighborhoods :ŽďƐΛdŚĞD,'͘ĐŽŵ boast a reasonable cost of living whether you prefer a more suburban setting or thriving city rich in theater, arts, and culture. Hershey, PA is home to the Hershey Bears hockey team and close to the Harrisburg Senators baseball team. The Susquehanna River, various ski slopes and the Appalachian Trail are in our Successful candidates require the following: backyard, offering many outdoor activities for all seasons. • Medical degree - M.D., D.O. or foreign equivalent • Completion of an accredited Internal Medicine Residency program • Eligibility to acquire a license to practice in the Commonwealth of Pennsylvania • Board eligible/certified in Internal Medicine

• No J1 visa waiver sponsorships available e Practice

For further consideration, please send your CV to: You’ve Always Brian McGillen, MD – Director, Hospital Medicine The Penn State Milton S. Hershey Medical Center is committed to afﬁ rmative Penn State Milton S. Hershey Medical Center Wanted in the

action, equal opportunity and the diversity of its workforce. Equal Opportunity c/o Heather Pefﬂ ey, PHR FASPR – Physician Recruiter Employer – Minorities/Women/Protected Veterans/Disabled. Hometown  hpefﬂ [email protected] Physician owned and managed You’ve Always  Enjoy an outstanding employment package Dreamed About  Bask in the beauty of a mild climate, stunning lakes and Hospitalist positions pristine national forests are now available.

Learn more at NOW RECRUITING new team members who share our UNIVERSITY OF MICHIGAN NAzHospitalists.com passion for hospital medicine. Sandy: [email protected] Talk to us about becoming part DIVISION OF HOSPITAL MEDICINE (928) 771-5487 of the NAzH team.

NORTHERN ARIZONA The University of Michigan, Division of Hospital Medicine seeks BC/BE internists to join NAzH HOSPITALISTS

our growing and dynamic division. Hospitalist duties include teaching of medical residents and NazHospitalists.com  Prescott, Arizona students, direct patient care in our non-resident and short-stay units and involvement in quality improvement and patient safety initiatives. Novel clinical platforms that feature specialty concentrations (hematology/oncology service, renal transplant service and bone marrow transplant teams) as well as full-time nocturnist positions are also available. Our medical short PITTSBURGH stay unit provides care for both observation and inpatient status patients and incorporates advanced practice The Department of Medicine at University of Pittsburgh and UPMC is providers as part of the medical team. seeking an experienced physician as an overall director of its Academic Hospitalist Programs within five teaching hospitals. The individual The ideal candidate will have trained at, or have clinical experience at a major US academic medical center. will be responsible for development of the strategic, operational, Sponsorship of H1B and green cards is considered on a case-by-case basis for outstanding individuals. Research clinical and financial goals for Academic Hospital Medicine and will RSSRUWXQLWLHVDQGKRVSLWDOLVWLQYHVWLJDWRUSRVLWLRQVDUHDOVRDYDLODEOHIRUTXDOLÀHGFDQGLGDWHV$QHGXFDWLRQDOORDQ work closely with the Medical Directors of each the five Academic Hospitalist programs. We are seeking a candidate that combines forgiveness program provides up to $50,000 in loan forgiveness for qualifying educational loans. academic and leadership experience. The faculty position is at the Associate or Professor level. Competitive compensation based on 7KH8QLYHUVLW\RI0LFKLJDQLVDQHTXDORSSRUWXQLW\DIÀUPDWLYHDFWLRQHPSOR\HUDQGHQFRXUDJHVDSSOLFDWLRQV qualifications and experience. from women and minorities. Requirements: Board Certified in Internal Medicine, significant experience managing a Hospitalist Program, and highly experienced Mail or email cover letter and CV to: as a practicing Hospitalist. Mail Vineet Chopra, MD, MSc, Chief, Division of Hospital Medicine, Interested candidates should submit their curriculum vitae, a brief UH South Unit 4, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5226 letter outlining their interests and the names of three references to: Email [email protected] Wishwa Kapoor, MD c/o Kathy Nosko 200 Lothrop Street, 933 West MUH • Pittsburgh, PA 15213 [email protected] • Fax 412 692-4825 WWW.MEDICINE.UMICH.EDU/HOSPITAL-MEDICINE EO/AA/M/F/Vets/Disabled

Looking to ll an open position? to adadvertisevertise in the Hospitalist or the Journal of Hospital Medicine, contact:

Heather Gonroski • 973-290-8259 • [email protected] OR Linda WilsonWilson • 973-290-8243 • [email protected]

To learnlearn more,more, visit www.the-hospitalist.org and click “Advertise”

48 THE HOSPITALIST I DECEMBER 2017 I www.the-hospitalist.org Make your next smart move. Visit www.shmcareercenter.org

Hospitalist Opportunity Available HOSPITALISTS/ NOCTURNISTS The Berkshires ~ Western MA NEEDED IN SOUTHEAST LOUISIANA Berkshire Health Systems is currently seeking BC/BE Internal Medicine & Med/Peds physicians to join our comprehensive Hospitalist Department • Day, Evening and Nocturnist positions • 7 on/7 off 10 hour shift schedule • Previous Hospitalist experience is preferred Ochsner HHealthealth SSystemystem iiss sseekingeeking pphysicianshysicians ttoo jjoinoin oourur Located in Western Massachusetts Berkshire Medical Center is the region’s leading provider of comprehensive health care services hospitalist team. BC/BE Internal Medicine and Family Medicine • 302-bed community teaching hospital physicians are welcomed to apply. Highlights of our opportunities are: $PDMRUWHDFKLQJDI¿OLDWHRIWKH8QLYHUVLW\RI0DVVDFKXVHWWV0HGLFDO6FKRRO • The latest technology including a system-wide electronic health record y $FORVHG,&8&&8 Hospital Medicine was established at Ochsner in 1992. We have a stable 50+ member $IXOOVSHFWUXPRI6SHFLDOWLHVWRVXSSRUWWKHWHDP group We understand the importance of balancing work with a healthy personal y7 on 7 off block schedule with flexibility lifestyle yDedicated nocturnists cover nights • Located just 2½ hours from Boston and New York City 6PDOOWRZQ1HZ(QJODQGFKDUP yBase plus up to 50 K in incentives • Excellent public and private schools yAverage census of 14-18 patients • World renowned music, art, theater, and museums • Year round recreational activities from skiing to kayaking, this is an ideal yE-ICU intensivist support with open ICUs at the community hospitals IDPLO\ORFDWLRQ yEPIC medical record system with remote access capabilities %HUNVKLUH+HDOWK6\VWHPVRIIHUVDFRPSHWLWLYHVDODU\DQGEHQH¿WVSDFNDJH yDedicated RN and Social Work Clinical Care Coordinators LQFOXGLQJUHORFDWLRQ yCommunity based academic appointment Interested candidates are invited to contact: y Liz Mahan at The only Louisiana Hospital recognized by US News and World Report Distinguished [email protected] or apply online at Hospital for Clinical Excellence award in 4 medical specialties www.berkshirehealthsystems.org yCo-hosts of the annual Southern Hospital Medicine Conference yWe are a medical school in partnership with the University of Queensland providing clinical training to third and fourth year students yLeadership support focused on professional development, quality improvement, and

yOpportunities for leadership development, research, resident and medical student teaching ySkilled nursing and long term acute care facilities seeking hospitalists and mid-levels with an interest in geriatrics yPaid malpractice coverage and a favorable malpractice environment in Louisiana yGenerous compensation and benefits package 2FKVQHU+HDOWK6\VWHPLV/RXLVLDQD·VODUJHVWQRQSURILWDFDGHPLFKHDOWKFDUHV\VWHP Driven by a mission to Serve, Heal, Lead, Educate and Innovate, coordinated clinical and KRVSLWDOSDWLHQWFDUHLVSURYLGHGDFURVVWKHUHJLRQE\2FKVQHU·VRZQHGPDQDJHGDQG affiliated hospitals and more than 80 health centers and urgent care centers. Ochsner is the only Louisiana hospital recognized by U.S. orld Report as a “Best Hospital” across four specialty categories caring for patients from all 50 states and more than 80 countries worldwide each year. Ochsner employs more than 18,000 employees and over 1,100 physicians in over 90 medical specialties and subspecialties, and conducts more than 600 clinical research studies. For more information, please visit ochsner.org and follow us on Twitter and Facebook. Interested physicians should email their CV to [email protected] or call 800-488-2240 for more information. Reference # SHM2017. Sorry, no opportunities for J1 applications.

Ochsner is an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, disability status, protected veteran status, or any other characteristic protected by law

To learn more, visit www.the-hospitalist.org and click “Advertise”or contact Heather Gonroski • 973-290-8259 • [email protected] or Linda Wilson • 973-290-8243 • [email protected]

www.the-hospitalist.org I DECEMBER 2017 I THE HOSPITALIST 49 Make your next smart move. Visit www.shmcareercenter.org

“ CEP America is trustworthy, THIS IS transparent, and has great physician leaders. This is our YOUR practice, and we get involved.”

PRACTICE Amina Martel, MD Excellent opportunity for a Hospital employed Hospitalist and practicing HOSPITAL MEDICINE PARTNER Hospitalist Program Director. The positions are inclusive of ICU responsibilities, which would include procedures such as vent management, intubation and central lines. Four Hospitalists provide 24/7 coverage to our 97 bed hospital, working a seven CEP America currently has hospitalist, intensivist, INTERESTED IN TRAVEL? on-seven o schedule, and rotate days and nights every three and skilled nursing practices in California, Illinois, Check out our Reserves Program. months New Jersey, Oregon, and Washington, some with LOOKING TOWARD MANAGEMENT? sign-on bonuses up to $100,000. Located in the Northeast, in the beautiful mountainous Apply for our Administrative Fellowship. communities of Saranac Lake and Lake Placid, NY. Our climate, And we sponsor Visa candidates! provides the full benets of four seasons, and ample outdoor recreational activities such as hiking, skiing, golf, boating, biking, CALIFORNIA ILLINOIS Visit go.cep.com/myteam2017 snowshoeing, or simply taking in the beauty of the surrounding • Fresno • San Jose • Alton to see a full list of our hospitalist Adirondack Mountains. We have been a two time host of the winter Olympics (1932 and 1980) and continue to host many • Modesto • San Mateo • Belleville and leadership opportunities. sporting and world cup events, as well as the annual Ironman • • Redding San Francisco USA. These are safe, family friendly communities with excellent • Sacramento • Walnut Creek schools systems. • San Diego

NEW JERSEY OREGON WASHINGTON If you are interested in learning more about our opportunities, • Passaic • Roseburg • Edmonds please contact Joanne Johnson at 518-897-2706, or e-mail [email protected]

RUNNING ON EMPTY?

80% of physicians today are professionally To advertise in e Hospitalist or overextended or at capacity, leaving them e Journal of Hospitalist Medicine with no time to see additional patients

Physician burnout rates top 50% in latest Contact: Mayo study and work life balance continues to worsen Heather Gonroski • 973.290.8259 [email protected] or Linda Wilson • 973.290.8243 -RLQXVWRJHWIXOõOOHGSOXJLQWR [email protected] EnvisionPhysicianServices.com/RechargeYourCareer

We’re a national, physician-led organization that gives clinicians the opportunity and the ﬂexibility to grow.

Explore the NewNew SHM CareerCareer CenterCenter Now with expanded capabilities, including: • Full mobile-optimization • Validated physician pro le — we’ve veri ed our candidates’ data • Contact information for MDs who view as well as apply to your jobs • Individual, customized landing pages for your job (available as an upgrade) And much more! www.shmcareers.org

50 THE HOSPITALIST I DECEMBER 2017 I www.the-hospitalist.org Make your next smart move. Visit www.shmcareercenter.org

Join Our Industry Leading Team Of PHYSICIAN ADVISORS & APPEALS AUTHORS

Learn More & Apply _vb1b-m7bvouĺ _rĺņņ0b|ĺѴņƑlƕƒ,u rr;-Ѵv|_ouĺ _rĺņņ0b|ĺѴņƑ_Ɣ-Ɛ Hospitalist Position in Picturesque Bridgton, Maine: Bridgton Hospital, part of the Central Maine Medical Family, seeks BE/BC Internist to join its well-established Hospitalist program. Candidates may choose part-time (7-8 shifts/month) to full- time (15 shifts/month) position. Located 45 miles west of Portland, Bridgton Hospital is located in the beautiful Lakes Region of Maine and boasts a wide array of outdoor activities including boating, kayaking, fishing, and skiing. Benefits include medical student loan assistance, competitive salary, highly qualified colleagues and excellent quality of life. For more information visit our website at www.bridgtonhospital.org Interested candidates should contact Julia Lauver, CMMC Physician Recruitment 300 Main Street, Lewiston, ME 04240 email: [email protected] call: 800/445-7431 fax: 207/755-5854

To learn more, visit www.the-hospitalist.org and click “Advertise”or contact Heather Gonroski • 973-290-8259 • [email protected] or Linda Wilson • 973-290-8243 • [email protected]

www.the-hospitalist.org I DECEMBER 2017 I THE HOSPITALIST 51 Make your next smart move. Visit www.shmcareercenter.org

Hospitalist/Nocturnist Opportunities in PA Starting Bonus and Loan Repayment Division of Hospital Medicine of Cooper University Hospital Board Certified/Eligible Internal Medicine and Family Medicine Hospitalists and Nocturnists St Luke’s University Health Network (SLUHN) has hospitalist and nocturnist opportunities in eastern The Division of Hospital Medicine of Cooper University Hospital seeks Pennsylvania for BC/BE physicians. Nocturnist opportunities are available at our Bethlehem Campus with motivated physicians to join a dynamic team of 80 physicians and 20 additional opportunities at our Anderson, Miners, Allentown and our newest hospital in Monroe County that nurse practitioners at more than ten locations in Southern New Jersey. opened in October of 2016. Highlights: • Full-time or part-time Hospitalist positions • Day or night shifts available We offer: • Flexible scheduling • Starting bonus and up to $100,000 in loan repayment • Teaching opportunities with residents and medical students • Emphasis on patient experience, quality and safety • 7 on/7 off schedules • Average encounter number of 14-18/day • Additional stipend for nights • Secure employment with low physician turnover • Attractive base compensation with incentive • Potential for career advancement in administrative, quality or educational roles • Excellent benefits, including malpractice, moving expenses, CME Cooper University Hospital is a 635 bed teaching hospital. We are the only tertiary care center and the first Advanced Certified Comprehensive Stroke SLUHN is a non-profit network comprised of physicians and 7 hospitals, providing care in eastern Center in Southern New Jersey. We employ more than 900 physicians and 325 trainees in all medical and surgical specialties. Cooper University Pennsylvania and western NJ. We employ more than 500 physician and 200 advanced practitioners. St. Hospital has its own on-campus medical school, the Cooper Medical Luke’s currently has more than 180 physicians enrolled in internship, residency and fellowship programs and School of Rowan University. The Cooper Health System maintains is a regional campus for the Temple/St. Luke’s School of Medicine. Visit www.slhn.org multiple partnerships with local and national institutions, including the MD Anderson Cancer Center. Our campuses offer easy access to major cities like NYC and Philadelphia. Cost of living is low coupled with Employment Eligibility: minimal congestion; choose among a variety of charming urban, semi-urban and rural communities your 0XVWEH%RDUG&HUWL¿HG(OLJLEOHLQ,QWHUQDORU)DPLO\0HGLFLQH family will enjoy calling home. For more information visit www.discoverlehighvalley.com Contact Information: Lauren Simon, Administrative Supervisor, 856-342-3150 Please email your CV to Drea Rosko at [email protected] [email protected] www.cooperhealth.org

ACADEMIC NOCTURNIST HOSPITALIST

The Division of General Internal Medicine at Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine (Hershey, PA) is seeking a BC/BE Internal Medicine NOCTURNIST HOSPITALIST to join our highly regarded team. Successful candidates will hold a faculty appointment to Penn State College of Medicine and will be responsible for the care in patients at Hershey Medical Center. Individuals should have experience in hospital medicine and be comfortable managing patients in a sub-acute care setting. Find your Our Nocturnists are a part of the Hospital Medicine program and will work in collaboration with advanced practice clinicians and residents. Primary focus will be on overnight hospital admission for patients to the Internal Medicine next job today! service. Supervisory responsibilities also exist for bedside procedures, and proficiency in central line placement, paracentesis, arthrocentesis, and lumbar puncture is required. The position also supervises overnight Code Blue and Adult Rapid Response Team calls. This position directly supervises medical residents and provides for teaching visit WWW.SHMCAREERS.ORG opportunity as well. Competitive salary and benefits among highly qualified, friendly colleagues foster networking opportunities. Excellent schools, affordable cost of living, great family-oriented lifestyle with a multitude of outdoor activities year-round. Relocation assistance, CME funds, Penn State University tuition discount for employees and dependents, LTD and Life insurance, and so much more!

Appropriate candidates must possess an MD, DO, or foreign equivalent; be Board Certified in Internal Medicine and have or be able to acquire a license to practice in the Commonwealth of Pennsylvania. Qualified applicants should upload a letter of interest and CV at: http://tinyurl.com/j29p3fz Ref Job ID#4524

For additional information, please contact: Brian Mc Gillen, MD — Director, Hospitalist Medicine

Penn State Milton S. Hershey Medical Center The Penn State Milton S. Hershey Medical Center is committed to affi rmative c/o Heather Peffl ey, PHR FASPR – Physician Recruiter action, equal opportunity and the diversity of its workforce. Equal Opportunity Employer – Minorities/Women/Protected Veterans/Disabled. hpeffl [email protected]

Expand your reach with an ad in the Journal of Hospital Medicine, SHM’s clinical content journal For rates or to place an ad, contact: Heather Gonroski • 973-290-8259 • [email protected] OR Linda Wilson • 973-290-8243 • [email protected]

Ask about our combination discount when advertising in both JHM and The Hospitalist.

To learn more, visit www.the-hospitalist.org and click “Advertise”

52 THE HOSPITALIST I DECEMBER 2017 I www.the-hospitalist.org Make your next smart move. Visit www.shmcareercenter.org

Physician-Led Medicine in Montana Hospitalist

BE/BC Hospitalist (Internal Medicine/Family Medicine) for Montana’s premier tertiary referral center and accredited Chest Pain Center. • Flexible scheduling, day/night openings Billings Clinic is nationally Our HM physicians are gifted. recognized for clinical • Work-life balance excellence and is a proud member of the Mayo Clinic Starting with a company-funded 401k at 10%. • Generous compensation Care Network. Located in package Billings, Montana – this friendly college community • Integrated 50+ specialty is a great place to raise a group practice family near the majestic • “America’s Best Rocky Mountains. Exciting outdoor recreation Town of 2016” close to home. 300 days Contact: Rochelle Woods of sunshine! 1-888-554-5922 physicianrecruiter@ billingsclinic.org billingsclinic.com

At US Acute Care Solutions, we value Hospitalist physicians and the remarkable gifts they bring to integrated acute care medicine–and it shows. Our physicians enjoy industry-leading 401k, ground- breaking paid parental leave, unbeatable leadership opportunities and more. Best of all, every full-time physician in our group becomes an equity owner in USACS. Our unique physician ownership creates integrated synergy that enables us to deliver what we all want: the power to make a positive impact in the hospitals and communities that we serve. Discover more at usacs.com/HMjobs.

Visit usacs.com/HMjobs or call us at 1-844-863-6797. [email protected]

To learn more, visit www.the-hospitalist.org and click “Advertise”or contact Heather Gonroski • 973-290-8259 • [email protected] or Linda Wilson • 973-290-8243 • [email protected]

www.the-hospitalist.org I DECEMBER 2017 I THE HOSPITALIST 53 Make your next smart move. Visit www.shmcareercenter.org

ENRICHING EVERY LIFE WE TOUCH… INCLUDING YOURS! Gundersen Health System in La Crosse, WI is seeking an IM or FM trained hospitalist Hospitalist—Charlottesville, VA to join its established team. Gundersen is an award winning, physician-led, integrated Sentara Martha Jefferson Hospital, is health system, employing nearly 500 physicians. currently recruiting for a full time hospitalist and Practice highlights: • 7 on 7 o schedule (26 weeks per year) with majority of shifts less than nocturnist to join our hospitalist team. 12 hours in length Our hospital offers a wide array of patient services, • Collaborative, cohesive hospitalist team established in 2002 with high retention with excellent subspecialty and ancillary support. rate and growth We strive to create an environment where safety • 26-member internal medicine hospitalist team comprised of 16 physicians and 10 associate sta and quality are the cornerstones to delivering • Primary responsibility is adult inpatient care exceptional healthcare. • Manageable daily census We offer competitive salary, benefits, and a • Excellent support and collegiality with subspecialty services cohesive work environment. • Direct involvement with teaching family medicine and/or internal medicine residents Nocturnist schedule – 6 nights on/8 off (7p-7a) • Competitive compensation and benets package, including loan forgiveness with in-house APC cross cover support. La Crosse is a vibrant city, nestled along the Mississippi River. The historic downtown Charlottesville is a university town, consistently and riverfront host many festivals and events. Excellent schools and universities, parks, sports venues, museums and aordable housing make this a great place to call home. rated as one of the best places to live, raise a family, with excellent schools, metropolitan For information contact Kalah Haug, Medical Sta Recruitment, at dining, and outdoor activities. [email protected]. or (608) 775-1005. Not a J-1/H1-B Visa opportunity. To apply please submit cover letter and CV to Equal Opportunity Employer [email protected] Gundersen Lutheran Medical Center, Inc. | Gundersen Clinic, Ltd. | 21972_0317 Paul Tesoriere, M.D. at or call (434) 654-7580.

Division Chief ~ Hospital Medicine Division

The Department of Medicine at the University of Rochester—Strong Memorial Hospital is currently seeking a new Division Chief for our Hospital Medicine Division. This Division comprises of 35 full and part-time faculty members who not only assist with the care of a large inpatient medical service but also play a key role in the department’s educational programs. This position reports directly To advertise in e Hospitalist or to the Chairman of the Department of Medicine. Ideal candidates will have leadership experience, e Journal of Hospitalist Medicine excellent interpersonal skills, expertise in quality improvement and a strong interest in medical education. The Hospital Medicine Division is noted for providing high quality education to a broad array of learners including outstanding residents in our Internal Medicine and Medicine-Pediatrics Contact: residency programs. Several members of the division have been recognized at the national level for Heather Gonroski • 973.290.8259 their academic educational contributions and scholarship. The University of Rochester Medical Center [email protected] is the premier academic health center in upstate New York. Visit our web site to learn more about or our innovative Department and our regional health system. Appropriate candidates must possess an MD or DO or foreign equivalent; be Board Certified in Internal Medicine; and meet NY state licensing Linda Wilson • 973.290.8243 requirements. Applicants should have achieved an academic rank of Associate Professor or higher; [email protected] possess excellent communication and organizational skills and a strong work ethic. Send CV and Cover letter to: [email protected] EOE Minorities/Females/Protected Veterans/Disabled

Now you have more digital options available for your recruiting • The country’s largest, 100%-validated U.S. physician database— the only one that’s BPA audited • Candidates who are guaranteed to be licensed, practicing U.S. physicians • Banner and native ads in the SHM member e-newsletter • Customized searches to match your job to the exact physician pro les you want

To learn more, visit www.the-hospitalist.org and click “Advertise”or contact Heather Gonroski • 973-290-8259 • [email protected] or Linda Wilson • 973-290-8243 • [email protected]

54 THE HOSPITALIST I DECEMBER 2017 I www.the-hospitalist.org Make your next smart move. Visit www.shmcareercenter.org

HOSPITALISTS & NOCTURNISTS Johnston Memorial Hospital, located in Historic Abingdon, Virginia, is currently seeking Full Time BE/BC, Day Shi Hospitalists and Nocturnists to join their team. ese are Full Time positions with the following incentives: ● Hospital Employed (earning potential up to $300k per year) ● Day Shi (7 days on -7 days o) (7am - 7pm) ● Night Shi (7 days on -7 days o) (7pm - 7am) ● Competitive Annual Salary ● Performance Bonus & Production Bonus ● Excellent Benets ● Generous Sign On Bonus ● Relocation and Educational Loan Assistance ● Teaching and Faculty opportunities with the JMH FM/IM Residency Training Programs ● Critical Care Physician Coverage in CCU/PCU Please view our online job tour: www.mshajobtour.com/jmh Please Contact: Tina McLaughlin, CMSR, Johnston Memorial Hospital Oce (276) 258-4580, [email protected]

Hospitalists Philadelphia, PA

Einstein Healthcare Network is seeking Hospitalists in both Philadelphia and Elkins Park, PA (Einstein Practice Plan, Inc., Elkins Park, PA). In this role, you will diagnose and treat inpatient patients, providing continuous care; prescribe medications and treatment regimens; admit patients for hospital stays; write patient discharge summaries; conduct discharge planning and discharge patients; order and interpret results of tests, such as laboratory and x-rays; communicate with primary care physicians; refer patients to medical specialists, social services or other professionals as needed; attend inpatient consultations in areas of specialty; apply leadership and teaching skills; utilize medical simulation; and supervise up to 3 physician assistants. Qualifications include MD or DO (or foreign equivalent); Pennsylvania medical license; 36 months of ACGME-approved residency in internal medicine; 12 months as a Hospitalist or similar; and experience in an acute care setting, including ICU patient care, ventilation management, cardiac stress tests, EKG interpretation and emergency department management that included ACS and acute stroke patients. EHN offers a compensation package, including CME allowance, a pension plan, excellent health insurance, coverage for relocation expenses, and other benefits.

Reply to Kim Hannan at [email protected].

EOE

To learn more, visit www.the-hospitalist.org and click “Advertise”or contact Heather Gonroski • 973-290-8259 • [email protected] or Linda Wilson • 973-290-8243 • [email protected]

www.the-hospitalist.org I DECEMBER 2017 I THE HOSPITALIST 55 Make your next smart move. Visit www.shmcareercenter.org

NOCTURNIST and Staff Opportunities Earn More, Work Less, Enjoy Work-Life Balance

Culture of Caring: Central Maine Medical Center has served the people of Maine for more than 125 years. We are a 250 bed tertiary care facility that attracts regional referrals and offers a comprehensive array of the highest level healthcare services to approximately 400,000 people in central and western Maine. Our experienced and collegial hospitalist group cares for over half of the inpatient population and is proud of our high retention rate and professionalism. The Opportunity: Nocturnist and staff positions: We are seeking BC/BE IM or FM physicians to work in a team environment with NP and PA providers. Nocturnists are supported by physician and NP/PA swing shift staff, full-time hours are reduced and compensation is highly incented. We also offer: • The opportunity to expand your professional interests in areas such as our nationally recognized Palliative Care team and award-winning Quality Improvement initiatives. • Encouragement of innovation and career growth at all stages starting with mentoring for early hospitalists, and progressing to leadership training and opportunities. • The only Hospital Medicine Fellowship in northern New England with active roles in fellow, resident and medical student education. What we can do for you: Welcome you to a motivated, highly engaged, outstanding group that offers a competitive compensation package with moving expense reimbursement, student loan assistance and generous sign-on bonus. We also value your time outside of work, to enjoy the abundance of outdoor and cultural opportunities that are found in our family-friendly state. Check out our website: www.cmmc.org. And, for more information, contact Gina Mallozzi, CMMC Medical Staff Recruitment at [email protected]; 800/445-7431 or 207/344-0696 (fax).

INSPIRE greatness At Mercy Medical Group, a service of Dignity Health Medical Foundation, we lead by example. By always striving to give our personal best—and encouraging our patients and colleagues to do the same—we’re able to achieve and do more than we ever imagined. If you’re ready to inspire greatness in yourself and others, join us today. HOSPITALISTS - Sacramento, CA Full-time and part-time openings are available, as are opportunities for Nocturnists. At our large multi-specialty practice with approximately 400 providers, we strive to offer our patients a full scope of healthcare services throughout the Sacramento area. Our award-winning Hospitalist program has around 70 providers and currently serves Find your 4 major hospitals in the area. Sacramento offers a wide variety of activities to enjoy, including fine dining, shopping, biking, boating, river rafting, skiing and cultural events. Our physicians utilize leading edge technology, including EMR, and enjoy a comprehensive, excellent compensation and benefits package next job today! in a collegial, supportive environment. For more information, please contact: Physician Recruitment Phone: 888-599-7787 | Email: [email protected] www.mymercymedgroup.org visit WWW.SHMCAREERS.ORG www.dignityhealth.org/physician-careers These are not J1 opportunities.

Looking to ll an open position? to adadvertisevertise in the Hospitalist or the Journal of Hospital Medicine, contact:

Heather Gonroski • 973-290-8259 • [email protected] OR Linda WilsonWilson • 973-290-8243 • [email protected]

To learnlearn more,more, visit www.the-hospitalist.org and click “Advertise”

56 THE HOSPITALIST I DECEMBER 2017 I www.the-hospitalist.org Make your next smart move. Visit www.shmcareercenter.org

Nocturnist Hospitalist Opportunity Hendersonville, NC (Near Asheville!) Employed Nocturnist Hospitalist opportunity. Full Time, seven on/seven off, 7:00 pm - 7:00 am. Average 6 - 8 admissions/consults per shift. Employed opportunity offers competitive base salary plus wRVU incentive, annual quality bonus, CME/Dues allowance, sign-on, relocation, paid professional liability insurance. Pardee Hospital is licensed for 222-beds and is a county, not- for-profit hospital affiliated with UNC Health Care. Must be BC in IM, FP or HM. Live in the “Land-of-Sky,” with the unmatched scenic beauty of the southern Appalachian Mountains and located in one of the fastest growing regions in North Carolina. The area boasts a great public school system as well as a wide variety of private and charter schools. The area is regularly featured in travel magazines and major publications as an area that attracts vacationers, retirees, and families because of the safety of the community and exceptional quality of life. No Recruitment or Placement Firm Inquiries. No Visa sponsorship. Contact: Lilly Bonetti, Physician Recruiter office (828) 694-7687 email [email protected] w ww.pardeehospital.org

Physician Research Scientist Position in Hospital Outcomes Research Kaiser Permanente, Northern California’s Division of Research (KPNC DOR) Physician Led, seeks an investigator with strong informatics expertise to develop an independently funded research program, conduct scholarly research, and collaborate with KPNC clinicians and leadership in evaluating or developing interventions to enhance the delivery of evidence-based hospital care. Patient Focused. The investigator may be appointed at the assistant professor, associate professor, or professor-equivalent level. This position will be part of an established DOR program, the Systems Research Initiative (SRI), which focuses on the processes and outcomes of hospital care, hospitalization/ rehospitalization prevention, and use of advanced analytics (including cloud FEATURED OPPORTUNITIES computing, machine learning, and provision of clinical decision support in real time). The SRI has tight links to KPNC leadership and EMR staff and Rutherford Regional Medical Memorial Medical Rapides Regional Medical draws on granular data from KPNC’s 22 hospitals’ > 250,000 annual discharges. The SRI plays an important role in developing new approaches Center Center – Nocturnist Center Rutherfordton, NC Las Cruces, NM Alexandria, LA used by KPNC for hospital performance benchmarking. Preferred qualifications include an MD or equivalent plus appropriate research Newark Hospitalist Practice – Redmond Regional Ocala Hospitalist Practice – experience (masters, PhD, and/or fellowship) in clinical informatics, health Staff Physicia Medical Center – Nocturnist services research, statistics, and/or clinical epidemiology. Opportunities Nurse Practitioner Medical Director Ocala, FL for clinical practice are available, as it is desirable that the successful Newark, DE Rome, GA candidate remain connected with hospital care. 6W$QWKRQ\·V² Please email a letter of interest and curriculum vitae to: Barstow Community Hospital Amsterdam Medical Director Barstow, CA M e m o r i a l H o s p i t a l – Northwest Indiana, IN Gabriel J. Escobar, MD Medical Director Email: [email protected] Amsterdam, NY and please cc: [email protected] Regional Director for Hospital Operations Research Join our team Director, Systems Research Initiative teamhealth.com/join or call 855.762.1651 Kaiser Permanente Division of Research

To learn more, visit www.the-hospitalist.org and click “Advertise”or contact Heather Gonroski • 973-290-8259 • [email protected] or Linda Wilson • 973-290-8243 • [email protected]

www.the-hospitalist.org I DECEMBER 2017 I THE HOSPITALIST 57 ON THE HORIZON I By Win Whitcomb, MD, MHM Choosing location after discharge wisely A novel, important skill for the inpatient team

By Win Whitcomb, MD, MHM

f all the care decisions we make Oduring a hospital stay, perhaps the one with the biggest implications for cost and quality is the one determining the location to which we send the patient after discharge. Yet ironically, we haven’t typically partic- ipated in this decision, but instead have left it up to case managers and others to Dr. Whitcomb is chief work with patients to determine discharge medical officer at Remedy location. This is a missed opportunity, as Partners in Darien, Conn., patients first look to their doctor for guid- and cofounder and past ance on this decision. Absent such guid- president of the Society of ance, they turn to other care team members Hospital Medicine. Contact for the conversation. With a principal focus Perhaps most striking of all, hospitalist care (versus that him at wfwhit@comcast. on hospital length of stay, we have prior- net. itized when patients are ready to leave over of traditional primary care providers) has been associated where they go after they leave. Discharge location has a large impact on with excess discharge rates to skilled nursing facilities, quality and cost. The hazards of going to a post-acute facility are similar to the hazards and savings that accrue under hospitalists during hospi- of hospitalization – delirium, falls, infection, and deconditioning are well-documented talization are more than outweighed by spending on care adverse effects. We may invoke the argu- during the post-acute period. ment that, all things being equal, a facility is safer than home. Yet, there is scant evidence supporting this assertion. At the same time, when contemplating a home discharge, a Identifying patient factors informing also the differing capabilities of home health capable caregiver is often in short supply, an optimal discharge location may repre- agencies, skilled nursing facilities, inpatient and patients requiring assistance may have sent a new skill set for many hospitalists rehabilitation facilities, and long-term acute few options but to go to a facility. and underscores the value of collabora- care hospitals. In terms of cost during hospitalization tion with team members who can provide and for the 30 days after discharge, for needed information. In April, the Society References common conditions such as pneumonia, of Hospital Medicine published the Revised 1. Mechanic R. Post-acute care – the next frontier for control- heart failure, chronic obstructive pulmo- Core Competencies in Hospital Medicine. ling Medicare spending. N Engl J Med. 2014;370:692-4. nary disease, or major joint replacement, In the Care of the Older Patient section, the 2. Newhouse JP, et al. Geographic variation in Medicare Medicare spends nearly as much on post- authors state that hospitalists should be able services. N Engl J Med. 2013;368:1465-8. acute care – home health, skilled nursing to “describe post-acute care options that can 3. Kuo YF, et al. Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a facilities, inpatient rehabilitation, long-term enable older patients to regain functional cohort study. Ann Intern Med. 2011;155(3):152-9. 1 4 acute care hospitals – as for hospital care. capacity.” Inherent in this competency is 4. Nichani S, et al. Core Competencies in Hospital Medicine Further, an Institute of Medicine analysis an understanding of not only patient factors 2017 Revision. Section 3: Healthcare Systems. J Hosp Med. showed that geographic variation in post- in post-acute care location decisions, but 2017 April;12(1):S55-S82. acute care spending is responsible for three- quarters of all variation in Medicare spending.2 Such variation raises questions about the rigor with which post-acute care decisions are made by hospital teams. Framework for selecting Perhaps most striking of all, hospitalist care (versus that of traditional primary care providers) has been associated with excess appropriate discharge location discharge rates to skilled nursing facilities, and savings that accrue under hospital- Patient Independence Skilled Nursing Needs ists during hospitalization are more than • Can the patient perform activi- • What, if anything, does the outweighed by spending on care during the ties of daily living? patient require in this area? post-acute period.3 • Can the patient ambulate? For example, a new PEG tube, All of this leads me to my point: Hospi- • Is there cognitive impairment? wound care, IV therapies, etc. talists and inpatient teams need a defined process for selecting the most appropriate Caregiver Availability Social Factors discharge location. Such a location should • If the patient needs it, is a • Is there access to transportation, ideally be the least restrictive location suit- caregiver who is capable and food, and safe housing? able for a patient’s needs. In the box at right, reliable available? If so, to what I propose a framework for the process. The extent is s/he available? Home Factors domains listed in the box should be evalu- • Are there stairs to enter the ated and discussed by the team, with early Therapy Needs house or to get to the bedroom input and final approval by the patient and • Does the patient require physi- or bathroom? caregiver(s). The domains listed are not cal, occupational, or speech • Has the home been modified to intended to be an exhaustive list, but rather therapy? accommodate special needs? Is to serve as the basis for discussion during • How much and for how long? the home inhabitable? discharge team rounds.

58 THE HOSPITALIST I DECEMBER 2017 I www.the-hospitalist.org