Social Determinants of Health and the Hospitalist Are Access to Housing and Food As Important As Therapeutics?

February 2020 HM20 PREVIEW KEY CLINICAL QUESTION IN THE LITERATURE Volume 24 No. 2 Course director When is a troponin Cardiac rehab p6 Dr. Benji K. Mathews p14 elevation an acute MI? p16 after valve surgery

Social determinants of health and the hospitalist Are access to housing and food as important as therapeutics?

By Larry Beresford

hile physicians acknowledge that the social determinants of health can impact outcomes from medical care, Wsome may feel that trying to address factors such as homelessness, food insecurity, or lack of ready access to transportation or pharma- cy services is just not part of the doctor’s job. A majority of 621 physicians surveyed in the summer of 2017 by Salt Lake City–based health care intelligence firm Leavitt Partners say they are neither capable of nor responsible for addressing such issues.1

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01_8_9_10_HOSP20_02.indd 1 1/22/20 2:37 PM SOCIETY NEWS February 2020 Volume 24 No. 2 State of Hospital PHYSICIAN EDITOR THE SOCIETY OF HOSPITAL MEDICINE Danielle B. Scheurer, MD, SFHM, MSCR; Phone: 800-843-3360 [email protected] Fax: 267-702-2690 Website: www.HospitalMedicine.org Medicine Survey plays PEDIATRIC EDITOR Laurence Wellikson, MD, MHM, CEO Anika Kumar, MD, FAAP Vice President of Marketing & [email protected] Communications key role in operations COORDINATING EDITORS Lisa Zoks Dennis Chang, MD [email protected] Marketing Communications Manager THE FUTURE HOSPITALIST Results help establish hospitalist benchmarks Brett Radler Keri Holmes-Maybank, MD, FHM [email protected] KEY CLINICAL GUIDELINES Marketing Communications Specialist he Hospitalist recently accurate the data. Over the past 4 CONTRIBUTING WRITERS Caitlin Cowan Dani Babbel, MD; Larry Beresford; [email protected] spoke with Brian Schroe- years, SHM has improved the sub- Therese Borden; Tracy Cardin, ACNP-BC, SHM BOARD OF DIRECTORS der, MHA, FACHE, FHM, mission process of survey data – es- SFHM; Claire Ciarkowski, MD; President assistant vice president, pecially for practices with multiple Natalie Como, MD; Christopher Frost, MD, SFHM President-Elect THospital & Emergency Medicine, at locations. John Gerstenberger, MD; Abhinav Goyal, MD, MHS, FACC; Danielle Scheurer, MD, MSCR, SFHM Atrium Health Medical Group in Devin Horton, MD; Treasurer Charlotte, N.C., to discuss his par- How have the data in the report Richard Mark Kirkner; Joshua LaBrin, MD, Tracy Cardin, ACNP-BC, SFHM SFHM; Mark S. Lesney; Secretary ticipation in the State of Hospital impacted important business Jessica Nave, MD; Todd J. Ochs, MD; Rachel Thompson, MD, MPH, SFHM Medicine Survey, which is distrib- decisions for your group? Erica Remer, MD, FACEP; Immediate Past President uted every other year, and how he We rely heavily on the investment/ Austin Rupp, MD; Paul Sandroni, MD; Nasim Afsar, MD, MBA, SFHM Charlie M. Wray, DO, MS Board of Directors uses the resulting provider benchmark within the Steven B. Deitelzweig, MD, MMM, SFHM report to guide survey data. Over the years, as the FRONTLINE MEDICAL Bryce Gartland, MD, FHM important opera- investment/provider was decreas- COMMUNICATIONS EDITORIAL STAFF Flora Kisuule, MD, MPH, SFHM Executive Editor Kathy Scarbeck Kris Rehm, MD, SFHM tional decisions. ing nationally, our own investment/ Editor Richard Pizzi Mark W. Shen, MD, SFHM provider was increasing. Based on Creative Director Louise A. Koenig Jerome C. Siy, MD, SFHM Please describe the survey, we were able to closely Director, Production/Manufacturing Chad T. Whelan, MD, MHSA, FHM Rebecca Slebodnik your current evaluate our staffing models at role. each location and determine the ap- EDITORIAL ADVISORY BOARD FRONTLINE MEDICAL Geeta Arora, MD; Michael J. Beck, MD; COMMUNICATIONS ADVERTISING STAFF At Carolinas Hos- propriate skill mix–to-volume ratio. Harry Cho, MD; Marina S. Farah, MD, National Account Manager Mr. Schroeder pitalist Group, Through turnover and growth, we MHA; Stella Fitzgibbons, MD, FACP, FHM; Valerie Bednarz, 973-206-8954 we have approx- have strategically hired advanced Benjamin Frizner, MD, FHM; cell 973-907-0230 [email protected] Nicolas Houghton, DNP, RN, ACNP-BC; imately 250 providers at nearly practice providers to align our James Kim, MD; Melody Msiska, MD; Classi ed Sales Representative Venkataraman Palabindala, MD, SFHM; 20 care locations across North investment more closely with the Heather Gonroski, 973-290-8259 Raj Sehgal, MD, FHM; Rehaan Shaf e, MD; Carolina. Along with my specialty benchmark. Over the past 2 years, [email protected] Kranthi Sitammagari, MD; Linda Wilson, 973-290-8243 medical director, I am responsible our investment/provider metric Amith Skandhan, MD, FHM; [email protected] Lonika Sood, MD, FACP, FHM; for the strategic growth, program has decreased significantly. We Senior Director of Classi ed Sales development, and financial perfor- were able to accomplish this while Amanda T. Trask, FACHE, MBA, MHA, SFHM; Amit Vashist, MD, FACP; Tim LaPella, 484-921-5001 mance for our practice. continuing to provide appropriate Jill Waldman, MD, SFHM cell 610-506-3474 [email protected] care to our patients. We also utilize Advertising Of ces 7 Century Drive, How did you first become the Report to monitor performance Suite 302, Parsippany, NJ 07054-4609 involved with the Society of incentive metrics, staffing model 973-206-3434, fax 973-206-9378 Hospital Medicine? trends, and encounter/provider When I first entered the hospital ratios. medicine world in 2008, I was look- THE HOSPITALIST is the official newspaper of the THE HOSPITALIST (ISSN 1553-085X) is published Society of Hospital Medicine, reporting on issues monthly for the Society of Hospital Medicine by ing for an organization that sup- What would you tell people and trends in hospital medicine. THE HOSPITALIST Frontline Medical Communications Inc., 7 Century ported our specialty. My physician who are on the fence about reaches more than 35,000 hospitalists, physician Drive, Suite 302, Parsippany, NJ 07054-4609. Print assistants, nurse practitioners, medical residents, and subscriptions are free for Society of Hospital Medi- leaders at the time pointed me to participating in the survey – health care administrators interested in the practice cine members. Annual paid subscriptions are avail- SHM. Since the beginning of my and ultimately, purchasing the and business of hospital medicine. Content for able to all others for the following rates: THE HOSPITALIST is provided by Frontline Medical time as a member, I have attended finished product? Communications. Content for the Society Pages is Individual: Domestic – $195 (One Year), the Annual Conference each year, Do it! Our practice would never provided by the Society of Hospital Medicine. $360 (Two Years), $520 (Three Years), Canada/Mexico – $285 (One Year), $525 (Two Years), attended the SHM Leadership Acad- skip a submission year. The data Copyright 2020 Society of Hospital Medicine. 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The Canada/Mexico – $485 All Other Nations – $565 conference for 3 years – and will defending staffing decisions and Society of Hospital Medicine and Frontline Medical Student/Resident: $55 Communications will not assume responsibility for be presenting for the third time at clinical operations change with damages, loss, or claims of any kind arising from Single Issue: Current – $35 (US), $45 (Canada/ HM20. senior leadership within the orga- or related to the information contained in this Mexico), $60 (All Other Nations) Back Issue – $45 publication, including any claims related to the (US), $60 (Canada/Mexico), $70 (All Other Nations) nization. products, drugs, or services mentioned herein. POSTMASTER: Send changes of address (with old Why is it important that Letters to the Editor: [email protected] mailing label) to THE HOSPITALIST, Subscription Services, P.O. Box 3000, Denville, NJ 07834-3000. people participate in the Don’t miss your chance to submit The Society of Hospital Medicine’s headquarters State of Hospital Medicine data that will help put together is located at 1500 Spring Garden, Suite 501, RECIPIENT: To subscribe, change your address, Philadelphia, PA 19130. purchase a single issue, file a missing issue claim, Survey? the latest snapshot of the hospital or have any questions or changes related to your Participation in the survey is key medicine specialty. The State of Editorial Offices: 2275 Research Blvd, Suite 400, subscription, call Subscription Services at 1-833-836- Rockville, MD 20850, 240-221-2400, fax 240-221-2548 2705 or e-mail [email protected]. for establishing benchmarks for Hospital Medicine Survey is open our specialty. The more people now and runs through Feb. 16, 2020. BPA Worldwide is a global industry resource for verified audience data and participate (from various arenas Learn more and register to par- The Hospitalist is a member. like private groups, health system ticipate at hospitalmedicine.org/ To learn more about SHM’s relationship with industry partners, visit www.hospitalmedicine.com/industry. employees, and vendors), the more survey. February 2020 | 2 | The Hospitalist

02thru7_HOSP20_02.indd 2 1/22/20 2:42 PM SURVEY INSIGHTS Resetting your compensation Using the State of Hospital Medicine Report to bolster your proposal

By Paul Sandroni, MD this, we see hospitalists are earning more for similar productivity. The hospital reimbursement for n the ever-changing world of health care, one professional fees has not grown at the same rate thing is for sure: If you’re not paying atten- as compensation. Also, the collection per RVU has tion, you’re falling behind. In this column, I remained relatively flat over time. will discuss how you may utilize the Society It’s simple: Hospitalists are earning more and Iof Hospital Medicine (SHM) State of Hospital professional revenues are not making up the dif- Medicine Report (SoHM) to evaluate your current ference. This market change is driving hospitals compensation structure and strengthen your to invest more money to maintain their HMGs. business plan for change. For purposes of this ex- If your hospital hasn’t been responding to these ercise, I will focus on data referenced as Internal data, you will need a strong business plan to get Medicine only, hospital-owned Hospital Medicine buy in from your hospital administration. Groups (HMG). Now that you have evaluated the market Issues with retention, recruitment, or burnout change, it is time to put some optics on where may be among the first factors that lead you to your compensation falls in the current market. reevaluate your compensation plan. The SoHM When you combine your total compensation with Report can help you to take a dive into feedback your total RVU productivity, you can use the for these areas. Look for any indications that SoHM Report to evaluate the current reported Dr. Sandroni is director of operations, compensation may be affecting your turnover, in- benchmarks for Compensation per RVU. Plotting hospitalists, at Rochester (N.Y.) Regional Health. ability to hire, or leaving your current team frus- these benchmarks against your own compen- trated with their current pay structure. Feedback sation and any proposed changes can help your surrounding each of these factors may drive you administration really begin to see whether a report directly outlining these data points. to evaluate your comp plan but remain mindful change should be considered. Providing that clear Now that we have reviewed market change and that money is not always the answer. picture in relevance to the SoHM benchmark is how to visualize change between your current You may complete your evaluation and find the important, as a chart or graph can simplify your and proposed future state, I will leave you with data could suggest you are in fact well paid for C-suite’s understanding of your proposal. some final thoughts regarding other consider- the work you do. Even though this may be the By simplifying your example using Compen- ations when building your business plan: case, the evaluation and transparency to your sation per RVU, you are making the conversa- • Focus on only physician-generated RVUs. provider team may help flush out the real reason tion easier to follow. Your hospital leaders can • Consider Length of Stay impact on productivity. you are struggling with recruitment, retention, or clearly see the cost for every RVU generated and • Decide if Case Mix Index changes have impact- burnout. However, if you do find you have an op- understand the impact. This is not to say that ed your staffing needs. portunity to improve your compensation struc- you should base your compensation around • Understand your E and M coding practices in ture, remember that you will need a compelling, productivity. It is merely a way to roll in all com- reference to industry benchmarks. The SoHM data-driven case to present to your C-suite. pensation factors, whether quality related, per- Report provides benchmarks for billing practic- Let us start by understanding how the market formance based, or productivity driven, and tie es across the country. has changed over time using data from the 2014, them to a metric that is clear and easy for admin- • Lastly, clearly identify the issues you want to ad- 2016, and 2018 SoHM Reports. Of note, each report istration to understand. dress and set goals with measurable outcomes. is based on data from the prior year. Since 2013, Remember, when designing your new compen- There is still time for your group to be part of hospital-owned HMGs have seen a 16% increase in sation plan, you can reference the SoHM Report to the 2020 State of Hospital Medicine Report data total compensation while experiencing only a 9% see how HMGs around the country are providing by participating in the 2020 Survey. Data are be- increase in collections. Meanwhile RVU productiv- incentive and what percentage of compensation is ing accepted through Feb. 16, 2020. Submit your ity has remained relatively stable over time. From based on incentive. There are sections within the data at hospitalmedicine.org/2020survey. Administrative burden and burnout

In May 2019, SHM sent a letter to tional data suggest that more than tals whose professional focus is the Hospital Medicine indicated that U.S. Senators Tina Smith (D-Minn.) 50% of the physician workforce is general medical care of hospitalized an average of 5.1 full-time employ- and Bill Cassidy, MD, (R-La.) in sup- burned out. Excessive administra- patients. Their unique position ees, not including case managers, port of the Reducing Administrative tive burden is a major contributor in the health care system affords are required to navigate the audit Costs and Burdens in Health Care to physician burnout, which neg- hospitalists a distinct perspective and appeals process associated Act of 2019. In excerpts from the let- atively affects quality and safety and systems-based approach to with hospital stay status determi- ter below, the society details the link within the hospital and further confronting and solving challeng- nations. These are resources that between administrative burdens increases health care costs. Nota- es at the individual provider and should be directly used for patient and physician burnout. bly, the Reducing Administrative overall institutional level of the care, but are redirected toward reg- Costs and Burdens in Health Care hospital. In this capacity, hospital- ulation compliance, increasing cost roviders and hospital systems Act calls for a 50% reduction of ists experience multiple examples of care without increasing quality. expend countless resources, unnecessary administrative costs of administrative requirements di- Pboth time and dollars, adher- from the Department of Health & rectly detracting from patient care To read the entire letter, visit ing to unnecessary and excessive Human Services within the next 10 and redirecting finite resources hospitalmedicine.org/policy--advocacy/ administrative burdens instead years. away from care to meet compliance letters/shm-supports-the-reducing- of investing those resources in Hospitalists are front-line clini- demands. administrative-costs-and-burdens-in- providing quality patient care. Na- cians in America’s acute care hospi- A recent study in the Journal of health-care-act-of-2019/. the-hospitalist.org | 3 | February 2020

02thru7_HOSP20_02.indd 3 1/22/20 2:42 PM ANALYSIS The evolution of social media and visual abstracts in hospital medicine

By Charlie M. Wray, DO, MS scroll past the post and never view the article. Recognizing that social media heavily rely on n recent years, social media platforms like visual material to garner attention, Annals turned Twitter, Facebook, and Instagram have become to Andrew M. Ibrahim, MD, an architect turned popular gathering spots for clinicians to con- surgeon, to help them rethink their social media nect, engage, and share medical content. Medi- strategy. Using the design training he had previ- Ical journals, which often act as purveyors of this ously received in his career as an architect, Dr. content, have recognized social media’s growing Ibrahim created a simple visual tool that could power and influence and have begun looking for be used to capture the often complicated and ways to better engage their audiences. nuanced aspects of a research study. He called his In 2016, the Annals of Surgery was looking to creation a “visual abstract.” better disseminate the work being published in But what is a visual abstract? Simply, they are its pages and looked to Twitter as one way of ac- visual representations of the key findings of a published manuscript; or put another way, a “movie trailer” to the full manuscript. While Dr. Wray is a hospitalist at the University of they can take many California, San Francisco, and the San Francisco different forms and Veterans Affairs Medical Center. He also serves designs, they often con- as a digital media and associate editor for the sist of three key compo- Journal of Hospital Medicine. nents: (1) a simple, easy

BRAHIM to understand title,

M. I (2) a primary focus on by Dr. Ibrahim and his colleagues found that

NDREW outcomes, and (3) the articles tweeted with a visual abstract had an al- A use of visual cues or most eightfold increase in the number of Twitter images to help the read- impressions (a measure of social media dissemi- complishing this. At the time, most journals were er absorb and remember the take-home message. nation) and a threefold increase in article visits, posting only the title or a brief description of the This simplified delivery of complex information compared with those manuscripts tweeted with published manuscript and hoping their Twitter allows the producer to efficiently share complex the article title only.1 These results reflect what followers would click on the article link. As jour- findings in a format that allows for rapid visual- behavioral scientists have long understood: Hu- nal editors were finding, if the audience was not ization and interpretation. mans process visual data better than any other immediately familiar with the topic or able to Since its inception, several studies have ex- type of data.2 For instance, according to research quickly capture the nuances of the study, there amined the influence visual abstracts have on compiled by 3M, the company behind popular was a good chance the reader would continue to disseminating research. One study conducted sticky notes, visual data are processed 60,000 times faster than text and have been shown to improve learning by 400%.3 Likewise, digital mar- keters have found that pages with videos and images draw on average 94% more views than their text-only counterparts.4 This knowledge, along with the substantial difference in engagement and dissemination charac- teristics from Dr. Ibrahim’s study, was far beyond what anyone might have expected and started a trend in medicine that continues to grow today. Medical journals across all practices and disci- plines, including several leading journals, such as the New England Journal of Medicine, the Jour- nal of the American Medical Association, and the Journal of Hospital Medicine (JHM), are utilizing this new tool to help disseminate their work in social media. Visual abstracts have expanded beyond the social media sphere and are now frequently used in Grand Rounds presentations and as teaching tools among medical educators. JHM was one of the first journals to adopt the use of visual abstracts and has since published more than 150 in total. Given the growing popularity and expanded use EDICINE

M of visual abstracts, JHM recently began archiving them on the journal’s website to allow clinicians to OSPITAL

H use the material in their own creative ways. OF Visual abstracts are just one piece of the grow- OURNAL J ing enterprise in social media for JHM. Recogniz- February 2020 | 4 | The Hospitalist

02thru7_HOSP20_02.indd 4 1/22/20 2:42 PM ANALYSIS

ing the growing utilization of social media among medicine–based topics, called #JHMChat.5 This reaches beyond hospital medicine borders and physicians, JHM has taken a leading role in the forum has allowed hospitalists from across the partners with other specialties and interest use of online journal clubs. Since 2014, JHM has country, and around the world, to connect, net- groups to gain perspective and insights into run a monthly Twitter-based journal club that work, and engage around topics important to the shared topic areas. To date, #JHMChat has one of discusses recently published articles and hospital field of hospital medicine. The journal frequently the most robust online communities and continues to attract new followers each month. As social media use continues to expand among clinicians, engagement tools like visual abstracts and Twitter chats will certainly continue to grow. Given that more clinicians are scrolling through websites than flipping through journal pages, medical journals like JHM will continually look for novel ways to engage their audiences and create communities among their followers. While a former architect who now practices as a surgeon led the way with visual abstracts, it remains to be seen who will create the next tool used to capture our attention on the ever-evolving sphere of social media.

References 1. Ibrahim AM et al. Visual abstracts to disseminate research on social media: A prospective, case-control crossover study. Ann Surg. 2017;266(6):e46. 2. Tufte ER. The Visual Display of Quantitative Information. Second edition. Cheshire, Conn. Graphics Press, 2001. https:// search.library.wisc.edu/catalog/999913808702121. 3. Polishing Your Presentation. http://web.archive.org/ web/20001014041642/http://www.3m.com:80/meetingnetwork/ files/meetingguide_pres.pdf. Accessed May 28, 2017. 4. 7 reasons you need visual content in your marketing strat- EDICINE egy. https://medium.com/@nikos_iliopoulos/7-reasons-you- M need-visual-content-in-your-marketing-strategy-bc77ca5521ac.

OSPITAL Accessed 2017 May 28. H OF 5. Wray CM et al. The adoption of an online journal club to improve research dissemination and social media engagement OURNAL

J among hospitalists. J Hosp Med. 2018. doi: 10.12788/jhm.2987.

N PAC 2020 National Physician Advisor Conference April 27-29, 2020 • Loews Portofino Bay Hotel Orlando, Florida

ACPA is a not-for-profit, physician run organization. Learn more at: www.acpadvisors.org.

the-hospitalist.org | 5 | February 2020

02thru7_HOSP20_02.indd 5 1/22/20 2:42 PM PREVIEW Innovations to expect at HM20 Course director Dr. Benji K. Mathews offers highlights

enji K. Mathews, MD, SFHM, CLHM, chief Carrie Herzke, MD, of Johns Hopkins University, and inclusion in the workplace, with speakers of hospital medicine at Regions Hospital Baltimore; Daniel Dressler, MD, of Emory Univer- from both community and academic settings. in St. Paul, Minn., and director of point sity, Atlanta; Jordan Messler, MD, of Morton Plant There will be good sessions with gender equity of care ultrasound (POCUS) for hospital Hospital in Clearwater, Fla.; and Michelle Guidry, themes, practical tips in promotion and hiring Bmedicine at HealthPartners, is the course director MD, of the Southeast Louisiana Veterans Health practices. There are a couple workshops on gen- for the Society of Hospital Medicine’s 2020 Annu- Care System and Tulane University, both in New der equity; one to note is “Top 10 Ways for Men + al Conference (HM20), which will be held April Orleans. Women to Engage in Gender Equity.” 16-18 in San Diego. One of the highlights this year is that we’re Dr. Mathews, also an associate professor of trying to bring more gender equity into our Can you speak to the content that is medicine at the University of Minnesota, Minne- speaker lineup. Rarely will we targeted at nurse practitioners and apolis, sat down with the Hospitalist to discuss have only two male speakers physician assistants? the role of the course director in formulating the at a session, and I don’t think This is near and dear to my heart. Our goal this HM20 agenda, as well as highlighting some excit- we have any all-male panels, year was to highlight nurse practitionerss and ing educational sessions, workshops, and other jokingly called “manels” in the physician assistants in a track dedicated to them. events during the annual conference. past. We have a basic session called “Training Day: How to Onboard and Operationalize an Advanced In your role as course director for HM20, Are there some “tried-and- Practice Provider Workforce” – this is a “bread- did you have a particular theme you true” tracks or sessions and-butter” session presented by speakers who wanted to emphasize? Dr. Mathews that are returning in have built programs from the ground up. Other We did not go with a single theme, because we’re HM20? important sessions address how to advance the trying to provide a comprehensive educational I’d like to highlight the Clinical Mastery track. careers of NPs and PAs – “Professional Develop- and networking opportunity, so trying to fo- That was a new track last year, and has returned ment for NP/PAs” – and on mentorship, which cus the conference on a single theme a year in this year. That track is focused on helping hos- emphasizes a culture of partnership on projects advance did not seem very prudent. There are pitalists become expert diagnosticians at the like providing high quality, safe care. multiple themes, from health disparities to tech- bedside. “Pitfalls, Myths and Pearls in Diagnostic nology to education. For a field like hospital med- Reasoning” is one session to note in that track. Are there any workshops that attendees icine that’s rapidly evolving, we thought it best Another special focus this year within Clinical should take note of? to keep it open and instead further develop the Mastery will be on using the rational clinical One I would like to highlight is “Survive! The conference tracks: What new tracks can be creat- exam to augment your diagnostic skills. POCUS Apocalypse Adventure.” This highly ed, what older tracks can be maintained because anticipated offering is preregistration required, they have been highly successful, and which When programming the annual conference, hosted for the first time on day 1 of the main tracks do we retire? how do you balance the needs of conference. The workshop will introduce the community hospitalists with academic gamification of POCUS to hospitalists. Each par- Can you discuss some of the tracks at hospitalists? ticipant will be expected to perform ultrasound HM20? The value we have on the annual conference examinations and interpret their findings in The new track we have this year is a minitrack: committee is that there are a fair number of order to gather clues that will lead to the cure the Technology track. That track is meant to community hospitalists, advance practice clini- for a zombie apocalypse. There are a lot of risks examine the current and future technology that cians, representation from med-peds, and those in programming the Annual Conference, and will impact care delivery, including telehealth, of family practice, for instance. Generally, there gamification might be considered risky because wearables, apps for digital learning, and clinicians is a wide sampling of the decision makers from it’s new. But I think it has a very good chance of at the bedside. Innovation is at the core of hospi- across the specialty helping to program the success. tal medicine, and we’re constantly exploring how conference – it’s not just academic powerhous- to deliver efficient, timely, and effective care. “Fu- es. That said, it is hard to curate content that is What are some other innovations that the ture-casting” is important, and this track speaks solely for a specific subset of hospitalists with- annual conference committee has planned to that. out marginalizing other subsets. We don’t want for 2020? There are some old standards that I would also to isolate people. But a lot of our Rapid Fire top- One exciting addition is what we call “Breakfast recommend. The “Great Debate” is one of the ics address frontline hospitalists. This is content with an Expert.” This is a new rapid-fire didac- hardest to select, because while you can create a that will directly impact community hospital- tic session format where we have three experts great session title, we need to find two talented ists. And some of the content that we’re taking speak on different hot topics, such as “Nutritional speakers, as a debate between two experts is very a bit of risk on this year are in health equity Counseling” (led by Kate Shafto, MD), “Things I different than a presentation. The speakers take and disparities. Academic groups study this, but Wish I Knew Earlier in my Career” (Brad Sharpe, opposing sides on clinical decisions, the latest frontline clinicians deal with this every day, re- MD), and “Case-Based Controversies in Ethics.” literature reviews, best practices, and the audi- lating to both patients and staff. For example, in These take place on the very first day of the ence gets to vote. Topics we are using this year regard to patients, we have content focused on conference, before the opening general session. include “Procalcitonin: Friend or Foe,” “Guidelines caring for the LGBTQ community and sessions Attendees can grab their breakfast and listen to Controversies in Inpatient Care,” and “POCUS on refugee health, as well as hospitalists and any of these sessions before they head into the vs. Physical Exam.” Some of the debaters include global health. We have an emphasis on diversity Continued on following page February 2020 | 6 | The Hospitalist

02thru7_HOSP20_02.indd 6 1/22/20 2:42 PM PEDIATRICS Community pediatric care is diminishing Loss of pediatric inpatient units may be devastating

By Todd J. Ochs, MD child-friendliness and pediatric com- ness to a pediatric hospital, health petence, becoming uncomfortable de- problems in the community, and the he mantra of community livering almost any care for children availability of pediatric specialists. hospital administrators is (e.g., sedated MRIs and EEGs, x-rays 5. A condition for medical licen- that pediatric care does not and ultrasounds, ECGs and echocar- sure might be that a community- pay. Neonatal intensive care diograms, and emergency care). based pediatric subspecialist is Tpays. For pediatrics, it is similar to 3. In almost all hospitals, after required to care for a proportion of how football programs (Medicare pediatrics was gone eventually the uninsured or publicly insured patients) support minor sports (pe- so passed obstetrics (another less children in his or her area. diatrics and obstetrics) at colleges. remunerative specialty). Sick new- 6. Reimbursements for pediatric However, fewer even mildly sick borns need immediate, competent care need to rise enough to make newborns are cared for at communi- care. Most pediatric hospitalizations caring for children worth it. ty hospitals, which has led to a cen- are short term, often overnight. De- The major decision point regard- Dr. Ochs is in private practice at tralization of neonatal and pediatric laying newborn care is a medicolegal ing care for children cannot be Ravenswood Pediatrics in Chicago. care and a loss of pediatric expertise nightmare. Transferring a sick child financial, but must instead embrace He said he had no relevant financial at the affected hospitals. to a distant hospital, to stay a day or the needs of each affected commu- disclosures. Pediatric hospitalists are hired to 2, is counterintuitive, and exposes nity. If quality health care is a right, cover the pediatric floor, the emer- the child and his or her family to a and not a privilege, then it is time gency department, and labor and potentially dangerous drive or heli- to stop closing pediatric inpatient eroding community hospital pedi- delivery, then fired over empty pedi- copter ride. units, and, instead, look for creative atric expertise has catastrophic im- atric beds. The rationale expressed 4. As pediatric subspecialty care ways to better care for our children. plications for rural hospitals, where is that pediatricians have done such becomes more centralized, parents This process has led to pediatric parents may have to drive for hours a good job in preventive care that are asked to travel for hours to see care being available only in desig- to find a child-friendly emergency children rarely need hospitalization, a pediatric specialist. There are nated centers. The centralization of department. so why have a pediatric inpatient times when that is necessary (e.g., pediatric care has progressed from Is there an answer? unit? It is true that preventive care cardiovascular surgery). Pediatric 30 years ago, when most community 1. Hospitals are responsible for the has been an integral part of primary subspecialists, such as pediatric oto- hospitals had inpatient pediatric patients they serve, including chil- care for children. Significantly less laryngologists, then leave commu- units, to the search for innovative dren. Why should a hospital be able that 1% of child office visits result in nity hospitals, forcing even minor ways to fill pediatric beds in the mid- to close pediatric services so easily? hospitalization. surgeries (e.g., ear ventilation tubes) 90s (sick day care, flex- or shared 2. Every hospital that sees children, Advocate Health Care has closed to be done at a center. In rural areas, pediatric units), to the wholesale through the emergency department, inpatient pediatric units at Illinois this could mean hours of travel, lost closure of community pediatric inpa- needs to have a pediatrician available Masonic, on Chicago’s North Side, work days, and family disruption. tient beds, from 2000 to the present. to evaluate a child, 24/7. Good Samaritan in Downers Grove, 5. Children’s hospitals get unin- I have, unfortunately, seen this first- 3. There needs to be an observa- and Good Shepherd in Barrington. sured and publicly insured children hand, watching the rise of pediatric tion unit for children, with pediatric Units also have been closed at sent hundreds of miles, because mega-hospitals and the demise of staffing, for overnight stays. Mount Sinai in North Lawndale, there were no subspecialists in the community pediatrics. It is a simple 4. Pediatric hospitalists should be Norwegian American on Chicago’s community who would care for financial argument. Care for children staffing community hospitals. West Side, Little Company of Mary these children. simply does not pay nearly as well as 5. Pediatric behavioral health in Evergreen Park, and Alexian What is the solution, in our profit- does care for adults, especially Med- resources need to be available, e.g., Brothers in Elk Grove. focused health care system? icaid patients. Pediatricians are the inpatient psychiatry, partial hospi- As a Chicago-area pediatrician for 1. Hospitals’ Certificates of Need poorest paid practicing doctors (pub- talization programs, intensive out- more than 30 years, I have learned could include a mandate for pediat- lic health doctors are paid less). patient programs. several things about community- ric care. It is true that pediatricians always 6. Telehealth communication is based pediatric care: 2. Children’s hospitals could be have been at the forefront of pre- not adequate to address acute care 1. Pediatrics is a geographic spe- made responsible for community- ventive medicine, and that pediatric problems, because the hospital cialty. Parents will travel to shop, based care within their geographic patients almost always get better, in caring for the child has to have the but would rather walk or have a catchment areas. spite of our best-intentioned inter- proper equipment and adequate ex- short ride to their children’s medical 3. The state or the federal govern- ventions. So community-based pedi- pertise to carry out the recommen- providers. Secondary care should be ment could mandate and financially atricians admit very few patients. dations of the teleconsultant. community based, and hospitaliza- support community-based hospital With the loss of pediatric units, If we accept that our children will tion, if necessary, should be close by care. community hospitals lose their shape the future, we must allow as well. 4. Deciding what level of care comfort caring for children. This them to survive and thrive. Is health 2. Hospitals that ceased delivering might be appropriate for each com- includes phlebotomy, x-ray, trauma, care a right or a privilege, and is it pediatric inpatient care lost their munity could depend upon close- surgery, and behavioral health. And just for adults or for children, too?

Continued from previous page hosts a variety of hospital medicine skill devel- preregister. This aligns with larger SHM efforts to plenary. Hospitalists have asked for more content, opment areas. This is an interactive center where encourage hospitalists to be more confident with so we’re adding these as a response to that hun- attendees can learn to perform bedside proce- bedside procedures. ger for more educational content. This format is dures, during the first 2 days of the conference. supposed to be a bit cozier, with more Q&A. The Sim Center is slightly different than the To register for the 2020 Annual Conference, in- Another aspect of HM20 to highlight is the precourses, in that we are offering 1-hour blocks cluding precourses, visit https://shmannualcon- Simulation Center. The Sim Center is a space that of small-group instruction for which attendees ference.org/register/. the-hospitalist.org | 7 | February 2020

02thru7_HOSP20_02.indd 7 1/22/20 2:42 PM Social determinants Continued from page 1

But that view may become un- pharmacists embedded on our care facilities. We also focus on a lot of borhoods – all of which can affect a sustainable as the U.S. health care teams. They try to figure out the things physicians didn’t historically person’s well-being. Environmental system continues to advance toward best medicine for the patient but at think were within their wheelhouse. health may include compromised value- and population-based mod- the lowest cost. They meet individu- Hospitalists deal with these kinds air quality – which can impact pul- els of health care and as evidence ally with patients and do medication of issues every day, but may not monary health. Other issues include mounts that social factors are im- counseling, particularly for those label them as social determinants access to employment and child portant contributors to costly out- with polypharmacy issues.” of health,” Dr. Jacobs-Shaw said. He care, utility needs, and interpersonal comes, such as avoidable hospital emphasized that hospitalists should violence. readmissions or emergency room More equitable health care realize that they are not powerless A 2014 paper in Annals of Inter- visits. A recent report from the Dr. Jacobs-Shaw has long held a to address these issues, working in nal Medicine found that residence Robert Wood Johnson Foundation personal interest in issues of in- partnership with other groups in within a disadvantaged neigh- estimates that at least 40% of health clusiveness, diversity, and how to and out of the hospital. They should borhood was a factor in hospital also know that health care payers readmission rates as often as was Most hospitalists believe social increasingly are dedicating resourc- chronic pulmonary disease.4 A re- es to these issues. cent report on social determinants determinants of health are part of their “We just started trying to address of health by the National Institute job responsibilities … For these complex homelessness through a pilot in for Health Care Management notes dimensions, efforts to improve health Orange County, working with non- that patients with food insecurity profit organizations and philan- are 2.4 times more likely to go to must extend to sectors far beyond thropy to offer a transitional site of the emergency room, while those traditional health care. care for our patients who are being with transportation needs are 2.6 discharged from the hospital and times more likely.5 – Dr. Meltzer have housing insecurity issues, to What can health care leaders do get them transitioned into more se- to better equip their clinicians and outcomes are the result of social make health care more equitable cure housing,” Dr. Jacobs-Shaw said. teams to help patients deal with and economic factors, while only for historically underserved groups. CareMore also has a transportation this array of complex needs? Inter- 20% can be attributed to medical Asking how to have a bigger impact collaborative that offers no-cost, mountain Healthcare, based in Salt care.2 on these issues is what brought him, nonemergency transportation to Lake City, spearheaded in 2018 the “This is a hot topic – getting a lot after 13 years as a hospitalist on the medical appointments. “That’s meet- development of the Alliance for the of attention these days,” said hos- East Coast, to CareMore, a company ing them where they are at, based Determinants of Health, starting in pitalist and care transitions expert that has made addressing social on an assessment of their needs and the communities of Ogden and St. Ramon Jacobs-Shaw, MD, MPA, re- needs central to its care model. “In resources.” George, Utah. The Alliance seeks to gional medical officer for CareMore California, where I am based, we promote health, improve access to Health, a California-based physician- are a wraparound for patients who Social determinants defined care, and decrease health care costs led health delivery organization and are covered by Medicare Advantage The social determinants of health through a charitable contribution subsidiary of Anthem. “If you go plans. We are whatever the patient – social, environmental, and other of $12 million over 3 years to seed around the country, some doctors needs us to be.” nonmedical factors that contribute collaborative demonstration proj- still see social factors as the realm of He oversees a group of hospi- to overall health status and medical ects. the social worker. But large health talists, dubbed extensivists, who need – have been defined by the Lisa Nichols, assistant vice pres- care organizations are coming to provide advanced patient care and World Health Organization as: “con- ident for community health at recognize that social determinants Intermountain, said that, while are huge contributors to the health hospitalists were not directly in- of their members and to the out- We met with hospitalists … because volved in planning the Alliance, comes of their care.” hospitalists and ED physicians Hospitalists could be the natural we“ wanted their feedback on how to have become essential to the pa- providers to delve into the specific raise awareness of the social needs of tient-screening process for health psychosocial aspects of their pa- and social needs. tients’ lives, or try to figure out how patients. … They see the patients who “We met with hospitalists, emer- those factors contribute to health come in from the homeless shelters.” gency departments, and hospital care needs, Dr. Jacobs-Shaw said. – Ms. Nichols administrators, because we want- They typically confront such issues ed their feedback on how to raise while the patient is in the hospital awareness of the social needs of bed, but what are the steps that led chronic disease management. In the ditions in which people are born, patients,” she said. “They have good to the hospitalization in the first extensivist model, physicians and grow, live, work, and age.” That is a ideas. They see the patients who place? What will happen after the advanced practice nurses provide broad complex of overlapping social come in from the homeless shelters.” patient is discharged? comprehensive and coordinated and systems issues, but it provides a Other hospitals are subsidizing “For example, if patients lack care to patients with complex med- context for a broader understanding apartments for homeless patients transportation, how can they get ical issues, taking their scope of of the patient’s health and response being discharged from the hospi- to their follow-up medical appoint- practice beyond the hospital into to medical interventions. tal. CommonSpirit Health, the new ment in the primary care office in homes, post-acute care facilities, and Socioeconomic status is a huge de- national Catholic health care orga- order to manage their diabetes? If other settings, with a focus on keep- terminant. Level of education may nization formed by the 2019 merg- you can’t follow up with them, their ing patients healthier and reducing be more important than income if er of Dignity Health and Catholic diabetes could get out of control, readmission.3 the person lacks the health literacy Health Initiatives, has explored with complications as a result, such “Our patients get access to extra to navigate the system and access how to help create and sustain as an infected wound,” he said. An- services and resources, some of needed care. Housing instability affordable housing in the commu- other big issue is access to afford- which are available at our care cen- may include poor sanitation, sub- nities it serves. Investments like able medications. “CareMore has ters – which are one-stop outpatient standard dwellings, or unsafe neigh- this have inspired others, such as February 2020 | 8 | The Hospitalist

01_8_9_10_HOSP20_02.indd 8 1/22/20 2:37 PM Kaiser Permanente, to get involved community and cultural activities in supporting housing initiatives.6 like yoga and dance classes, cooking classes, art classes, and music con- Comprehensive community care certs. For these complex dimensions David Meltzer, MD, PhD, a hospital- and determinants of health, Dr. ist and professor of medicine at the Meltzer explained, efforts to improve University of Chicago, said most health must extend to sectors far be- hospitalists these days believe social yond traditional health care. determinants of health are part of “I think trying to understand your their job responsibilities. patients’ social and nonmedical “That’s not to say we all do it well. needs starts with getting to know We may fail at addressing some of them, and asking about their needs,” he said. “The better you know them, the better you are able to make medical decisions that will promote Large health care positive outcomes.” organizations“ are coming Sound Physicians, a national hospitalist company based in Tacoma, to recognize that social Wash., and working in 350 hospitals determinants are huge in 41 states, recently published a contributors to the health blog post on its website about the importance of social determinants of their members.” of health.7 Sound Physicians partic- – Dr. Jacobs-Shaw ipates in value-based care through HM20 is not your bundled Medicare/Medicaid con- tracts based on episodes of care for the barriers our patients face. But I hospitalized patients with certain average conference. don’t know anyone who still says it’s diagnoses or DRGs, explained John not their job,” he said. Dickey, MD, the company’s chief HM20’s schedule is packed with Since 2012, Dr. Meltzer has led a medical officer for population out-of-the-box learning experiences pilot called Comprehensive Care health. Physicians (CCP), in which the same “We’ve been heavily involved in to help you grow and connect you with physician cares for patients with trying to improve cost and out- the hospital medicine community. chronic health problems in the clinic comes of care since 2015. Social

We can … provide education for our hospitalist“ staff, and work with in- home care supports for patients … who otherwise might end up in a skilled nursing facility.” – Dr. Dickey “SHM’s Annual Conference, compared to other professional and in the hospital, working with a determinants absolutely play into team of nurse practitioners, social trying to lower costs of care and meetings I go to, can be workers, care coordinators, and reduce rates of readmissions, which other specialists. A total of 2,000 pa- are often multifactorial in cause,” diﬀerentiated by one word: tients with chronic health problems he said. Hospitalists are uniquely were enrolled in the study from 2012 equipped to impact post-acute out- energy. The amount of positive to 2016, half assigned to standard comes, Dr. Dickey said, working in excitement, collegiality and care and half assigned to five CCP partnership with a position Sound doctors. The result: The CCP mod- Physicians calls the clinical perfor- collaboration from all the el has shown large improvements mance nurse. in outcomes – particularly among “We can also partner with primary aendees is unparalleled.” the more vulnerable, less activated care providers, provide education patients – is preferred by patients, for our hospitalist staff, and work Brian Harte, MD, MHM and has significantly reduced health with in-home care supports for pa- care utilization. tients such as these, who otherwise The next step for the research might end up in a skilled nursing team is another randomized con- facility – even though they’d rather shmannualconference.org trolled trial called Comprehensive be at home,” he said. Care, Community, and Culture, de- signed to address unmet social needs. Innovations at Northwell Health Study group patients will also be Northwell Health, a multihospi- screened for unmet social needs and tal comprehensive health system have access to a community health serving the New York City metro worker and to the initiative’s Artful area and Long Island, has shown Living Program, which includes Continued on following page the-hospitalist.org | 9 | February 2020

01_8_9_10_HOSP20_02.indd 9 1/22/20 2:37 PM Continued from previous page innovations is its Food as Health shows that, no matter who we are, care, while AAFP has a research page innovative leadership in addressing Program, initially piloted at Long we can’t do the best work that our on its website dedicated to social de- social factors. The 23-hospital sys- Island Jewish Hospital in Valley patients need unless we consider terminants of health, highlighting a tem initiated in early 2019 a 15-item Stream, N.Y. Hospitalized patients their social determinants,” Dr. Marti- number of initiatives and resources Self-Reported Social Determinants are asked two questions using a nez said. Ultimately, she noted, there for physicians and others.9 Screening Tool, which is now used validated screening tool called the is a need to change the culture of The American Hospital Associ- with hospitalized patients to con- Hunger Vital ation has produced fact sheets on nect them with the support they Sign to identify ICD-10CM code categories for social need to fully recover and avoid read- their food inse- The research shows that, determinants of health, including 11 missions. curities.8 Those ICD-10 “Z” codes, numbered Z55-Z65, Northwell is also providing pro- who answer yes no“ matter who we are, we which can be used for coding in- fessional education on social deter- are referred to a can’t do the best work that terventions to address social determinants for different constituencies dietitian, and if minants of health. Other experts across its system, said Johanna they have a nu- our patients need unless are looking at how to adapt the Martinez, MD, MS, a hospitalist trition-related we consider their social electronic health record to capture and GME Director of Diversity and diagnosis, they determinants.” sociodemographic and behavioral Health Equity at the Zucker School enter the mul- factors, and then trigger referrals of Medicine at Hofstra/Northwell. tidisciplinary – Dr. Martinez to resources in the hospital and the A day-long training retreat was of- wraparound broader community, and how to fered to GME faculty, and learning program. health care. “We have to create sys- mobilize artificial intelligence and platforms have been developed for A key element is the food and tem change, reimbursement change, machine learning to better identify physicians, social workers, nurses, health center, located on the hospi- policy change.” social needs. and others. tal campus, where they can get food Omolara Uwemedimo, MD, MPH, “Our doctors really want to be able “One of the questions that comes to take home and referrals to other associate professor of pediatrics and to take care of the whole patient, up is that, if you find social needs, services, with culturally tailored, occupational medicine at North- while being stewards of health care what do you do about them?” Dr. disease-specific food education in- well and a former nocturnist, said resources. But sometimes we feel Martinez explained. That’s more a corporated into the discharge plan. the treatment of illness and health powerless and wonder how we can difficult challenge, she said, so at One of the partnering organizations improvement don’t begin in the hos- have a bigger impact on people, on Northwell, orthopedic surgeons are is Island Harvest Food Bank, which pital, they begin in the community. populations” Dr. Jacobs-Shaw said. now asking patients questions like: helps about 1 in every 10 residents of Identifying where people are strug- “Remember it only takes one voice “What’s going to happen when you Long Island with their food insecu- gling and what communities they within an organization to start to go home? What are your social sup- rity issues. come from requires a broader view elevate this topic.” ports? Can you get to the physical “When I talk to clinicians, most of of the provider’s role. “Are patients therapist’s office?” us went into medicine to save lives who are readmitted to the hospi- References Another example of Northwell’s and cure people. Yet the research tal generally coming from certain 1. Rappleye E. Physicians say social determi- demographics or from certain zip nants of health are not their responsibility. Beck- er’s Hospital Review. 2018 May 15. codes?” she asked. “Start there. How 2. Robert Wood Johnson Foundation, Univer- can we better connect with those sity of Wisconsin Population Health Institute. communities?” County Health Rankings, 2014. 3. Freeman GA. The extensivist model. Health Education as key to change Leaders Magazine. 2016 Sep 15. In 2020 and beyond, hospitalists will 4. Kind AJ et al. Neighborhood socioeconomic disadvantage and 30-day rehospitalization: A hear more about the social determi- retrospective cohort study. Ann Intern Med. nants of health, Dr. Jacobs-Shaw con- 2014 Dec 2;161(11):765-74. You can make a cluded. “With- out addressing difference at SHM. those social de- Are patients who are terminants, we aren’t going to readmitted“ to the hospital be able to mean- As a member of SHM, your voice and participation are integral generally coming from ingfully impact parts of our organization. Here are ways you can become more outcomes or be certain demographics or involved and identify yourself as a leader in hospital medicine: effective stew- from certain zip codes? ards of health Start there.” care costs – ad- – Dr. Uwemedimo Join a Committee dressing the psychosocial factors and root causes of patients 5. National Institute for Health Care Manage- Engage with special interest groups coming in and out of the hospital.” ment. Addressing social determinants of health can improve community health & reduce costs. He added that self-education is key 6. Vial PB. Boundless collaboration: A philos- for hospitalists and the teams they ophy for sustainable and stabilizing housing Connect at the local level with your chapter work with – to be more aware of the investment strategies. Health Progress: Journal link between health outcomes and of the Catholic Health Association of the United States. September-October 2019. social determinants. Guidelines and 7. Social determinants of health: New solutions Submit your research to JHM other resources on social determi- for growing complexities. Op-Med, a blog by nants of health are available from Sound Physicians. 2019 Aug 1. the American College of Physicians 8. The hunger vital sign: A new standard of care and the American Association of for preventive health. Learn more at Family Physicians. ACP issued a posi- 9. Daniel H et al. Addressing social determinants hospitalmedicine.org/engage to improve patient care and promote health tion paper on addressing social deter- equity: An American College of Physicians posi- minants of health to improve patient tion paper. Ann Intern Med. 2018;168:557-78. February 2020 | 10 | The Hospitalist

01_8_9_10_HOSP20_02.indd 10 1/22/20 2:37 PM COMMENTARY Work the program for NP/PAs, and the program will work A ‘knowledge gap’ in best practices exists

By Tracy Cardin, ACNP-BC, SFHM states, family NPs. For PAs, this is reflected in the variety of clinical rotations and pregraduate clin- ospital medicine has been the fastest ical exposure. growing medical specialty since the This variability is compounded, too, by the lack term “hospitalist” was coined by Bob of standardization of hospital medicine practices, Wachter, MD, in the famous 1996 New both with site size and patient acuity, a variety HEngland Journal of Medicine article (doi: 10.1056/ of challenges that drive the need for integration NEJM199608153350713). The growth and change of NP/PA providers, and by-laws that define ad- within this specialty is also reflected in the vanced practice clinical models and function. changing and migrating target of hospitals and In that perspective, it is important to define hospital systems as they continue to effectively what constitutes a leading and successful ad- and safely move from fee-for-service to a payer vanced practice provider (APP) integration pro- model that rewards value and improvement in gram. I would suggest: the health of a population – both in and outside 1. A structured and formalized transition-to- of hospital walls. practice program for all new graduates and In a short time, nurse practitioners and physi- those new to hospital medicine. This program cian assistants have become a growing population should consist of clinical volume progression, Ms. Cardin is currently the vice president of in the hospital medicine workforce. The 2018 State formalized didactic congruent with the Society advanced practice providers at Sound Physicians of Hospital Medicine Report notes a 42% increase of Hospital Medicine Core Competencies, and a and serves on SHM’s board of directors as its in 4 years, and about 75% of hospital medicine process for evaluating knowledge and decision treasurer. This article appeared initially at the groups across the country currently incorporate making throughout the program and upon Hospital Leader, the official blog of SHM. NP/PAs within a hospital medicine practice. This completion. evolution has occurred in the setting of a looming 2. Development of physician competencies re- and well-documented physician shortage, a variety lated to APP integration. Physicians are not physician level of volume. In 2016 State of of cost pressures on hospitals that reflect the need prepared in their medical school training or Hospital Medicine Report data, yearly billable for an efficient and cost-effective care delivery residency to understand the differences and encounters for NP/PAs were within 10% of that model, an increasing NP/PA workforce (the De- similarities of NP/PA providers. These compe- of physicians. I think 15% is a reasonable goal. partment of Labor notes increases of 35% and 36% tencies should be required and can best be de- 5. I mplementation and support of APP admin- respectively by 2036), and data that indicate simi- veloped through steady leadership, formalized istrative leadership structure at the system/ lar outcomes, for example, HCAHPS (the Hospital instruction ,and accountability for professional site level. This can be as simple as having Consumer Assessment of Healthcare Providers teamwork. APPs on the same leadership committees as and Systems), readmission, and morbidity and 3. Allowance for NP/PA providers to work at physician team members, being involved in mortality in NP/PA-driven care. the top of their skills and license. This means hiring and training newer physicians and NP/ This evolution, however, reveals a true knowl- utilizing NP/PAs as providers who care for pa- PAs or as broad as having all NP/PAs report to edge gap in best practices related to integration tients – not as scribes or clerical workers. The an APP leader. Having an intentional leader- of these providers. This is impacted by wide evolution of the acuity of patients provided for ship structure that demonstrates and reflects variability in the preparation of NPs – they may may evolve with the skill set and experience of inclusivity and belonging is crucial. enter hospitalist practice from a variety of clin- NP/PAs, but it will evolve – especially if steps 1 Consistent application of these frameworks ical exposures and training, for example, adult and 2 are in place. will provide a strong infrastructure for successful gerontology acute care, adult, or even, in some 4. Productivity expectations that reach near NP/PA practice. Developing guidance for patient movement requests

n hospital medicine, inpatients are lacking, so Dr. Stream sought to Creating institutional policy that ual patient requests for liberalized often request more freedom to develop a framework with which identifies relevant clinical, legal, and movement and work with other phy- Imove within the hospital complex hospitalists can approach patient re- ethical considerations will allow sicians, nurses, hospital administra- for a wide range of both benign and quests for liberalized movement. requests for increased movement tion, and risk management to devise potentially concerning reasons. For a small subset of patients, to be evaluated systematically and pertinent policy on this issue that “Hospitalists are often confronted liberalized movement within the transparently. is specific to their institutions. By with a dilemma when consider- hospital may be clinically feasible: “When patients request liberal- creating clear guidelines, providers ing these patient requests: how to those who are medically, physically, ized movement, hospitalists should will spend less time managing each promote patient-centered care and and psychiatrically stable enough to consider the requests systemat- individual request to leave the floor autonomy while balancing patient move off their assigned floors with- ically: first to identify the intent because they have a systematic strat- safety, concerns for hospital liability, out inordinate risk. “For the rest of behind requests, and then to follow egy for making consistent decisions. and the delivery of timely, efficient inpatients, movement outside their a framework to determine whether medical care,” said Sara Stream, MD, monitored inpatient settings may increased movement would be safe Reference a hospitalist at the VA New York interfere with appropriate medical and allow appropriate medical care 1. Stream S, Alfandre D. “Just getting a cup Harbor Healthcare System. Guidance care and undermine the indica- without creating additional risks,” of coffee” – Considering best practices for from medical literature and institutions for acute hospitalization,” Dr. Dr. Stream said. patients’ movement off the hospital floor. J tional policies on inpatient movement Stream said. Hospitalists should assess individ- Hosp Med. 2019 Nov. doi: 10.12788/jhm.3227. the-hospitalist.org | 11 | February 2020

11thru15_HOSP20_02.indd 11 1/22/20 2:43 PM CLINICAL The measles comeback of 2019

By Therese Borden than 140,000 people worldwide died amnesia” by impairing immune that maternal measles antibodies MDedge News from measles in 2018, according to memory is supported by early had dropped below the protective the World Health Organization and research showing children with threshold by 3 months of age – well easles made a comeback the CDC. measles had negative cutaneous before the recommended age of 12-15 in 2019. “[Recent data on measles indicate] tuberculin reactions after having months for the first dose of MMR The Centers for Dis- that during the first 6 months of the previously tested positive. vaccine. ease Control and Preven- year there have been more measles In this study, researchers com- The odds of inadequate protection Mtion reported that, as of Dec. 5, 2019, cases reported worldwide than in pared the levels of around 400 doubled for each additional month 1,276 individual cases of measles any year since 2006. From Jan. 1 to pathogen-specific antibodies in of age, Michelle Science, MD, of the were confirmed in 31 states, the larg- July 31, 2019, 182 countries reported blood samples from 77 unvaccinated University of Toronto and associates est number since 1992. This number 364,808 measles cases to the WHO. children, taken before and 2 months reported in Pediatrics (2019 Dec 1. is a major uptick in cases, compared This surpasses the 129,239 reported after natural measles infection, with doi: 10.1542/peds.2019-0630). with previous years since 2000 during the same time period in 2018. 5 unvaccinated children who did not “The widening gap between loss when the CDC declared measles WHO regions with the biggest in- contract measles. A total of 34 chil- of maternal antibodies and measles eliminated from the United States. creases in cases include the African dren experienced mild measles, and vaccination described in our study No deaths have been reported for region (900%), the Western Pacific re- 43 had severe measles. leaves infants vulnerable to measles 2019. gion (230%), and the European region They found that the samples tak- for much of their infancy and high- Three-quarters of these cases in (150%),” according to a CDC report. en after measles infection showed lights the need for further research 2019 were linked to recent outbreaks Studies on hospitalization and “substantial” reductions in the num- to support public health policy,” Dr. in New York and occurred in primar- complications linked to measles in ber of pathogen epitopes, compared Science and colleagues wrote. ily in underimmunized, close-knit the United States are scarce, but with the samples from children who The researchers randomly se- communities and in patients with two outbreaks in Minnesota (2011 did not get infected with measles. lected 25 samples for each of eight links to international travel. A total and 2017) provided some data of This amounted to approximately different age groups: up to 30 days of 124 of the people who got measles what to expect if the measles surge a 20% mean reduction in overall old, 1 month (31-60 days), 2 months this year were hospitalized, and continues into 2020. The investiga- diversity or size of the antibody (61-89 days), 3 months (90-119 days), 4 61 reported having complications, tors found that poor feeding was a repertoire. However, in children who months, 5 months, 6-9 months, and including pneumonia and enceph- primary reason for admission (97%); experienced severe measles, there 9-11 months. alitis. The overall median patient additional complications included was a median loss of 40% (range, Just over half the babies (56%) age was 6 years (31% aged 1-4 years, otitis media (42%), pneumonia (30%), 11%-62%) of antibody repertoire, were male, and 35% had an under- 27% aged 5-17 years, and 29% aged at and tracheitis (6%). Three-quarters compared with a median of 33% lying condition, but none had con- least 18 years). received antibiotics, 30% required (range, 12%-73%) range in children ditions that might affect antibody The good news is that most of oxygen, and 21% received vitamin who experienced mild infection. levels. The conditions were primar- these cases occurred in unvaccinat- A. Median length of stay was 3.7 Meanwhile, the control subjects re- ily a developmental delay or other- ed patients. The national vaccina- days (range, 1.1-26.2 days) (Pediatr tained approximately 90% of their wise affecting the central nervous tion rate for the almost 4 million Infect Dis J. 2019 Jun;38[6]:547-52. doi: antibody repertoire over a similar or system, liver, or gastrointestinal kindergartners reported as enrolled 10.1097/INF.0000000000002221). longer time period. Some children function. Mean maternal age was 32 in 2018-2019 was 94.7% for two dos- lost up to 70% of antibodies for spe- years. es of the MMR vaccine, falling just ‘Immunological amnesia’ cific pathogens. When the researchers calculated short of the CDC recommended 95% Infection with the measles virus the predicted standardized mean vaccination rate threshold. The CDC appears to reduce immunity to Maternal-acquired immunity antibody titer for infants with a reported an approximate 2.5% rate other pathogens, according to a pa- In another study of measles im- mother aged 32 years, they deter- of vaccination exemptions among per published in Science (2019 Nov munity, maternal antibodies were mined their mean to be 541 mIU/mL school-age children. 1;366[6465]599-606). found to be insufficient to provide at 1 month, 142 mIU/mL at 3 months The bad news is that, despite the The hypothesis that the measles immunity to infants after 6 months. (below the measles threshold of high rate of MMR vaccination rates virus could cause “immunological The study of 196 infants showed susceptibility of 192 mIU/mL), and among U.S. children, there are gaps 64 mIU/mL at 6 months. None of in measles protection in the U.S. Number of measles cases reported to the CDC, 2010-2019 the infants had measles antibodies population because of factors leav- above the protective threshold at 6 ing patients immunocompromised 1,400 months old, the authors noted. and antivaccination sentiment that Children’s odds of susceptibility to has led some parents to defer or re- 1,200 measles doubled for each additional fuse the MMR. month of age, after adjustment for In addition, adults who were vac- 1,000 infant sex and maternal age (odds cinated prior to 1968 with either in- ratio, 2.13). Children’s likelihood of activated measles vaccine or measles 800 susceptibility to measles modestly vaccine of unknown type may have increased as maternal age increased limited immunity. The inactivated 600 in 5-year increments from 25 to 40 measles vaccine, which was avail- years. 400 able in 1963-1967, did not achieve Children with an underlying con-

effective measles protection. EWS ditions had greater susceptibility to 200 N

EDGE measles (83%), compared with those

A global measles surge 0 MD without a comorbidity (68%, P = While antivaccination sentiment 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019* .03). No difference in susceptibility contributed to the 2019 measles cas- existed between males and females es, a more significant factor may be *Cases as of Dec. 5. or based on gestational age at birth the global surge of measles. More Source: National Center for Immunization and Respiratory Diseases, Division of Viral Diseases (ranging from 37 to 41 weeks). February 2020 | 12 | The Hospitalist

11thru15_HOSP20_02.indd 12 1/22/20 2:43 PM CLINICAL ID consult for Candida bloodstream infections

By Mark S. Lesney rate than did those who did not (29% vs. 51%). fewer patients in the ID consultation group were MDedge News With a model using inverse weighting by the untreated (2% vs. 14%; P less than .0001). propensity score, they found that ID consulta- In an accompanying commentary, Katrien La- linicians managing patients who have tion was associated with a hazard ratio of 0.81 grou, MD, and Eric Van Wijngaerden, MD, of the Candida bloodstream infection should for mortality (95% confidence interval, 0.73-0.91; P department of microbiology, immunology, and consider an infectious disease (ID) con- less than .0001). transplantation, University Hospitals Leuven sultation, findings from a large retro- In the ID consultation group, the median dura- (Belgium) stated: “We think that the high propor- Cspective study suggest. tion of patients (14%) with a Candida bloodstream Mortality attributable to Candida blood- infection who did not receive any antifungal stream infection ranges between 15% and 47%, treatment and did not have an infectious disease and delay in initiation of appropriate treatment consultation is a particularly alarming finding. ... has been associated with increased mortality. Ninety-day mortality in these untreated patients Previous small studies showed that ID consul- was high (67%).” tation has conferred benefits to patients with “We believe every hospital should have an Candida bloodstream infections. expert management strategy addressing all indi- Carlos Mejia-Chew, MD, and colleagues from vidual cases of candidaemia. The need for such

Washington University, St. Louis, sought to ex- OMMONS expert management should be incorporated in plore this further by performing a retrospective, C all future candidaemia management guidelines,”

single-center cohort study of 1,691 patients aged IKIMEDIA they concluded. /W

18 years or older with Candida bloodstream OLM The study was funded by the Astellas Global infection from 2002 to 2015. They analyzed de- C Development Pharma, the Washington University RAHAM

mographics, comorbidities, predisposing factors, G Institute of Clinical and Translational Sciences, all-cause mortality, antifungal use, central-line and the Agency for Healthcare Research and removal, and ophthalmological and echocardio- tion of antifungal therapy was significantly longer Quality. Several of the authors had financial con- graphic evaluation in order to compare 90-day (18 vs. 14 days; P less than .0001); central-line remov- nections to Astellas Global Development or other all-cause mortality between individuals with and al was significantly more common (76% vs. 59%; P pharmaceutical companies. Dr. Lagrou and Dr. without an ID consultation. less than .0001); echocardiography use was more Van Wijngaerden both reported receiving person- They found that those patients who received frequent (57% vs. 33%; P less than .0001); and oph- al fees and nonfinancial support from a number an ID consult for a Candida bloodstream infec- thalmological examinations were performed more of pharmaceutical companies, but all outside the tion had a significantly lower 90-day mortality often (53% vs. 17%; P less than .0001). Importantly, scope of the study.

March 5, 2020 is National Hospitalist Day. Celebrate with us. You and your institution can join SHM in honoring the hospital medicine team.

Share your stories and download shareable graphics. #HowWeHospitalist hospitalmedicine.org/hospitalistday

the-hospitalist.org | 13 | February 2020

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Key Clinical Question When is a troponin elevation an acute myocardial infarction? Misdiagnosis can have ‘downstream repercussions’

By Jessica Nave, MD, and Abhinav Goyal, MD, MHS, FACC

ospitalists encounter tropo- ican College of Cardiology, American type 2 MI is a relative (as opposed nin elevations daily, but we Heart Association, European Society to an absolute) deficiency in coro- have to use clinical judg- of Cardiology, and World Heart Fed- nary artery blood flow triggered by ment to determine if the eration. The term “NSTEMI” should an abrupt increase in myocardial Htroponin elevation represents either be used only when referring to a oxygen demand, drop in myocardial a myocardial infarction, or a non-MI type 1 MI not when referring to a blood supply, or both. In type 2 MI, troponin elevation (i.e., nonischemic type 2 MI.1 myocardial injury occurs second- myocardial injury). The diagnosis of a type 1 MI ary to an underlying process, and It is important to remember that (STEMI and NSTEMI) is supported therefore requires correct docu- Dr. Nave Dr. Goyal an MI specifically refers to myocar- by the presence of an acute coro- mentation of the underlying cause dial injury due to acute myocardial nary thrombus or plaque rupture/ as well. ischemia to the myocardium. This erosion on coronary angiography or Common examples of underlying Dr. Nave is assistant professor of lack of blood supply can be due to a strong suspicion for these when causes of type 2 MI include acute medicine in the division of hospital an acute absolute or relative de- angiography is unavailable or con- blood loss anemia (e.g., GI bleed), medicine at Emory University, ficiency in coronary artery blood acute hypoxia (e.g., COPD exacer- Atlanta. Dr. Goyal is associate flow. However, there are also many bation), shock states (cardiogenic, professor of medicine (cardiology), mechanisms of myocardial injury The diagnosis of a type 1 hypovolemic, hemorrhagic, or at Emory University, and chief unrelated to reduced coronary ar- myocardial infarction is septic), coronary vasospasm (e.g., quality officer, Emory Heart and tery blood flow, and these should be supported by evidence or spontaneous or cocaine-induced), Vascular Center, Emory Healthcare. more appropriately termed non-MI and bradyarrhythmias. Patients He is also codirector of nuclear troponin elevations. strong suspicion of acute with type 2 MI often have a history cardiology at Emory University Historically, when an ischemic coronary artery thrombus of fixed obstructive coronary dis- Hospital. mechanism of myocardial injury ease, which when coupled with the was suspected, providers would or plaque rupture/erosion. acute trigger facilitates the type 2 categorize troponin elevations into MI; however, underlying coronary type 2 MI may be favored, partic- ST-segment elevation MI (STEMI) traindicated (Figure 1). Type 1 MI artery disease (CAD) is not always ularly if there is evidence of an versus non-STEMI (NSTEMI) based (also referred to as spontaneous MI) present. underlying trigger for a supply-de- on the electrocardiogram (ECG). We is generally a primary reason (or Diagnosing a type 2 MI requires mand mismatch. In challenging would further classify the NSTEMI “principal” diagnosis) for a patient’s evidence of acute myocardial isch- cases, cardiology consultation can into type 1 or type 2, depending presentation to a hospital.2 Please emia (Figure 2) with an elevated help determine the MI type and/or on the mechanism of injury. The note that a very high or rising tro- troponin but must also have at least the next diagnostic and treatment term “NSTEMI” served as a “catch- ponin level alone is not diagnostic one of the following3: considerations. all” term to describe both type 1 for a type 1 or type 2 NSTEMI. The • Symptoms of acute myocardial When there is only elevated tro- NSTEMIs and type 2 MIs, but that lab has to be taken in the context of ischemia such as typical chest ponin levels (or even a rise and fall classification system is no longer the patient’s presentation and other pain. in troponin) without new symptoms valid. supporting findings. • New ischemic ECG changes. or ECG/imaging evidence of myocar- As of Oct. 1, 2017, ICD-10 and the In contrast to a type 1 MI (STEMI • Development of pathological Q dial ischemia, it is most appropriate Centers for Medicare & Medicaid and NSTEMI), a type 2 MI results waves. to document a non-MI troponin ele- Services have a new ICD-10 diagno- from an imbalance between myo- • Imaging evidence of new loss of vation due to a nonischemic mecha- sis code for type 2 MI (I21.A1), dis- cardial oxygen supply and demand viable myocardium, significant nism of myocardial injury. tinct from NSTEMI (I21.4) based on unrelated to acute coronary144411a artery reversibleIMNG perfusion Print Colors defect on Headline for a Bar Graphic updated definitions from the Amer- thrombosis or plaque rupture. A nuclear imaging, or new regional If a deckNon-MI headline troponin is needed, elevationuse this style. wall motion abnormality in a pat- (nonischemic myocardial injury) tern consistent with an ischemic Label Thestyle numberand size of conditions known Figure 1. Classication of MI etiology. to cause myocardial injury through Distinguishing a type 1 NSTEMI Axes numbermechanisms style and other size than myocardial MI Type Classication from a type 2 MI depends mainly onNote: Tradeischemia Gothic is Medium, growing, 8/11 especially ush left in the clinical context and clinical judg- the current era of high-sensitivity 1 STEMI (acute coronary artery thrombosis) Source: Trade Gothic Medium, 8/11 ush left 4 NSTEMI (acute coronary artery plaque rupture/erosion) ment. A patient whose presenting troponin assays. symptoms include acute chest dis- Common examples of underlying 2 Supply/demand mismatch (heterogeneous underlying causes) Style Guide: comfort, acute ST–T-wave changes, causes of non-MI troponin elevation 3 Sudden cardiac death with ECG evidence of acute myocardial ischemia before Keep the background white. and a rise in troponin would be sus- include: cardiac troponins could be drawn Use the IMNG colors.

EWS pected of having a type 1 NSTEMI. • Acute (or chronic) systolic or di-

N Move the entire graph to align the bar labels left at the blue guide bar. 4 MI due to percutaneous coronary intervention However, in a patient presenting astolic heart failure usually due 5 MI due to coronary artery bypass grafting EDGE (Resizing may need to be done on the graph to t in the space.) MD with other or vague complaints to acute ventricular wall stretch/ MDedge News where an elevated troponin was If a deeperstrain. or Troponin shorter template elevations is tendneeded, adjust in Window > Artboards. Source: Dr. Nave and Dr. Goyal found amongst a battery of tests, a (Standard,to be mild, as shown with morehere, indolentis 28 picas (or x 20 picas.) To create the dotted lines if they change, use the clear arrow tool, click February 2020 14 The Hospitalist on the line that needs to be changed, use the eyedropper tool, then | | click on the dotted rule provided on the side of the template.

11thru15_HOSP20_02.indd 14 1/22/20 2:43 PM 144411b

even flat) troponin trajectories. • Stroke/intracranial hemorrhage: Figure 2. Is my patient with elevated troponin having an MI? • Pericarditis and myocarditis due Mechanisms of myocardial injury IMNG Print Colors Headline for a Bar Graphic to direct injury from myocardial and troponin elevation are in- Elevated troponin If a deck headline is needed, use this style. inflammation. completely understood, but may • Cardiopulmonary resuscitation include catecholamine surges that Label style and size (CPR) due to physical injury to injure the heart. Clinical evidence of overt myocardial ischemia No overt myocardial ischemia Axes number style and size the heart from mechanical chest Some underlying conditions • New acute myocardial ischemia symptoms and/or • No ischemic symptoms, ECG changes, • New or dynamic ischemic ECG changes and/or or imaging ndings Note: Trade Gothic Medium, 8/11 ush left compressions and from electrical can cause a type 2 MI or a non-MI • Imaging shows new infarction, wall motion • Serial troponins may show rise and shocks of external defibrillation. troponin elevation depending on abnormality, or perfusion abnormality fall, or may show little variation Source: Trade Gothic Medium, 8/11 ush left • Stress-induced (takotsubo) cardio- the clinical context. For example, • Serial troponins show characteristic rise and fall (“at” troponins) myopathy: stress-induced release hypertensive emergency, severe Style Guide: of neurohormonal factors and aortic valve stenosis, hypertrophic Keep the background white. Acute coronary thrombus or Clinical context Document “Non-MI troponin catecholamines that cause direct cardiomyopathy, and tachyarrhyth- plaque rupture on angiography supports myocardial elevation secondary to Use the IMNG colors. myocyte injury and transient dila- mias (including atrial fibrillation (or strongly suspected when oxygen supply- [underlying cause]” Move the entire graph to align the bar labels left at the blue guide bar. tation of the ventricle. with rapid ventricular response) angiography unavailable or demand mismatch otherwise contraindicated) (Resizing may need to be done on the graph to t in the space.) • Acute pulmonary embolism: result may cause increased myocardial ox- If a deeper or shorter template is needed, adjust in Window > Artboards. of acute right ventricular wall ygen demand, and in patients with (Standard, as shown here, is 28 picas x 20 picas.)

underlying CAD, could precipitate a Document “Type 1 MI” Document “Type 2 EWS

N To create the dotted lines if they change, use the clear arrow tool, click type 2 MI. (e.g. “STEMI” or MI secondary to Misdiagnosing an MI “NSTEMI”) [underlying cause]” EDGE on the line that needs to be changed, use the eyedropper tool, then

However, these same conditions MD MDedge News when“ the patient does could cause a non-MI troponin ele- click on the dotted rule provided on the side of the template. not have one can have vation in patients without CAD and Source: Dr. Nave and Dr. Goyal could also cause myocardial injury multiple downstream and troponin release by causing recover with treatment of sepsis), volume overload, and not demand repercussions. Because acute left ventricular stretch/strain. this was most likely myocardial inju- ischemia). Generally, it is uncommon Distinguishing the diagnose of type ry via direct cell toxicity, and should for a heart failure exacerbation to it stays on their medical 2 MI vs. non-MI troponin elevation be documented as a non-MI tropo- cause a type 2 MI. record, it impacts their depends on documenting whether nin elevation due to sepsis without there are ancillary ischemic symp- shock. Importance of a correct ability to get insurance. toms, ECG findings, imaging, and/ If there were ischemic ECG diagnosis ” or cath findings of acute myocardial changes and the patient had chest Misdiagnosing an MI when the pa- stretch/strain, not from myocardi- ischemia. pain, one would have to use clinical tient does not have one can have al ischemia. suspicion to differentiate between multiple downstream repercussions. • Sepsis without shock: direct toxic- Case examples a type 1 NSTEMI and a type 2 MI. If Because it stays on their medical ity of circulating cytokines to car- 1. A 60-year-old male presents with there is a high clinical suspicion for record, it impacts their ability to get diac myocytes. In the absence of fever, cough, shortness of breath, an acute plaque rupture/thrombus, insurance and their premium costs. evidence of shock and symptoms/ and an infiltrate on chest x-ray and one would call it an NSTEMI and We expose patients to additional med- signs of myocardial ischemia, do is diagnosed with sepsis secondary would have to document treatment ications (e.g., dual-antiplatelet therapy, not document type 2 MI. to pneumonia. His initial troponin as such (e.g., start heparin drip). statins), which can have adverse ef- • Renal failure (acute kidney injury of 0.07 (normal < 0.05) rises to 0.11, Again, cardiology consultation can fects. As a result, it is very important or chronic kidney disease): multiple peaks at 0.23, then subsequently be helpful in cases where it may to classify the etiology of the tropo- etiologies, but at least partially re- trends down. be hard to decide how to manage. nin elevation and treat accordingly. lated to reduced renal clearance of While some may be tempted to Many times, the true mechanism Finally, when we incorrectly label troponin. In general, renal failure diagnose a type 2 MI, remember that is not determined until the patient a patient as having an MI, this can in the absence of symptoms/signs sepsis can cause direct myocardial is taken to the cath lab and if no impact billing and reimbursement, of ischemia is best classified as a cell injury via direct cell toxicity. acute plaque rupture is seen, then DRG denials, insurance premiums, non-MI troponin elevation. End- Unless this patient had at least one it was likely a type 2 MI. and quality metrics for both the stage renal disease patients who additional criteria (anginal chest 2. A 70-year-old male with chronic hospital and the physicians. Hos- present with volume overload due pain, new ischemic ECG changes, systolic heart failure, noncompliant pitals’ 30-day readmission rates for to missed dialysis also typically or imaging evidence of new loss of with medications, presents with 3 acute MI will suffer and quality have a non-MI troponin elevation. viable myocardium, which does not days of dyspnea on exertion and metrics can be significantly impact- lower extremity edema. He had ed. We must be diligent and as pre- Key Points no chest discomfort. Exam shows cise as possible with our diagnoses bibasilar crackles and hepatojugu- and documentation to ensure the • A diagnosis of a type 1 MI is supported by evidence or strong suspi- lar reflux. ECG shows no ischemic maximum benefit for our patients cion of acute coronary artery thrombus or plaque rupture/erosion. changes. Serial troponin values and our health care system. • A very high troponin level alone is not diagnostic for a type 1 or type over 48 hours were 0.48, 0.58, 0.51. 2 MI. It has to be contextualized with the patient’s presentation and A transthoracic echocardiogram References other supporting findings. reveals an left ventricular ejection 1. Goyal A et al. What’s in a name? The new • Type 2 MI is a mismatch between myocardial oxygen supply and fraction of 40% with poor move- ICD-10 (10th revision of the international statistical classification of diseases and related health demand unrelated to acute coronary thrombosis or plaque rupture ment in the apex, similar to his problems) codes and type 2 myocardial infarc- triggered by an abrupt increase in myocardial oxygen demand, drop prior echo. tion. Circulation. 2017;136:1180-2. in myocardial blood supply, or both. Type 2 MI should be documented This patient had no overt evi- 2. Goyal A et al. Translating the fourth universal along with its underlying cause. dence of ischemia (no chest pain, definition of myocardial infarction into clinical documentation: Ten pearls for frontline clini- • For diagnosis of an MI (either type 1 or type 2 MI), in addition to the ischemic ECG, or imaging changes) cians. Cardiology Magazine. Nov 2018. troponin elevation, the patient must have symptoms of acute ischemia, so the troponin elevation was most 3. Thygesen K et al. Fourth universal definition of ischemic ECG findings, and/or imaging suggestive of new ischemia. likely a non-MI troponin elevation myocardial infarction (2018). J Am Coll Cardiol. • An elevated troponin level without new symptoms or ECG/imaging secondary to acute or chronic systol- 2018;Aug 25:(Epub ahead of print). evidence of myocardial ischemia should be documented as a non-MI ic heart failure (in which the mech- 4. Roongsritong C et al. Common causes of troponin elevations in the absence of acute troponin elevation secondary to an underlying cause. anism of troponin elevation is left myocardial infarction: incidence and clinical ventricular chamber stretch from significance. Chest. 2004;125:1877-84. the-hospitalist.org | 15 | February 2020

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In the Literature Clinician reviews of HM-centric research

By Dani Babbel, MD; Claire Ciarkowski, MD; Natalie Como, MD; John Gerstenberger, MD; Devin Horton, MD; Joshua LaBrin, MD, SFHM; Austin Rupp, MD University of Utah, Salt Lake City

IN THIS ISSUE verity of AC, though do not specify coronary syndrome (ACS) survivors optimal timing. Existing literature affect quality of life and depression? 1. Cardiac rehab after cardiac valve surgery associated with reduced mor- is conflicting on when ERCP should BACKGROUND: Depression after tality ideally be done for AC. ACS is common and is associated 2. Emergent ERCP in acute cholangitis linked with better outcomes STUDY DESIGN: Systematic review with increased mortality. Profes- 3. Depression screening after ACS does not change outcomes and meta-analysis. sional societies have recommended 4. Family-involved interventions reduce postoperative delirium SETTING: Literature search involv- routine depression screening in 5. Dapagliflozin may cut risk of HF hospitalization in patients with type 2 ing PubMed, Medline, and Embase these patients; however, this has diabetes databases. not been consistently implemented 6. Metoprolol increases severity, but not risk, of COPD exacerbations SYNOPSIS: Nine studies with 7,534 because there is a lack of data to 7. In-hospital mobility impairment in older MI patients predicts postdis- patients were included in the final support routine charge functional decline meta-analysis. Emergent ERCP was screening. 8. New guidelines on the diagnosis and treatment of adults with CAP associated with a lower in-hospital STUDY DESIGN: 9. PCI and CABG for left main disease have equal outcomes at 5 years mortality (IHM; odds ratio, 0.52; Multicenter ran- 10. The role of aspirin in primary prevention of cardiovascular disease 95% confidence interval, 0.28-0.98) domized clinical 11. Longitudinal associations between income changes and incident CVD and shorter length of stay (LOS; trial. mean difference, –2.87 days; 95% CI, SETTING: Four –1.55 to –4.18), compared to urgent geographically By Dani Babbel, MD that for patients with systolic heart ERCP. The IHM mortality differ- diverse health sys- Cardiac rehab after cardiac failure or after CABG. Major study ence was true for both patients Dr. Ciarkowski tems in the United 1 valve surgery associated limitations were the lack of general- with severe AC (as defined by ev- States. with reduced mortality izability to younger patients because idence of end-organ dysfunction) SYNOPSIS: In the CODIACS-QoL all patients examined were older and mild-moderate AC. There was trial, 1,500 patients were randomized CLINICAL QUESTION: Does cardiac than 64 years. a trend toward lower 30-day mor- to three groups within 12 months of rehabilitation (CR) improve out- BOTTOM LINE: Racial and geo- tality in patients who underwent documented ACS: depression screen- comes for patients after undergoing graphic factors influence the rate emergent ERCP, though it did not ing with notification to primary cardiac valve surgery (CVS)? of enrollment in CR for patients un- reach statistical significance. care and treatment, screening and BACKGROUND: National guidelines dergoing CVS. All patients should be The studies included in the anal- notification to primary care, and no recommend CR after CVS. However, encouraged to participate in CR af- ysis were observational studies, so screening. Only 7.7% of the patients neither enrollment in CR nor its ter CVS because it is associated with no causal relationship can be estab- in the screen, notify, and treat group benefits have been well described in reduced 1-year mortality and risk of lished. Only two of the nine studies and 6.6% of screen and notify group this population. hospitalization. reported outcome differences strati- screened positive for depression. STUDY DESIGN: Observational co- CITATION: Patel DK et. al. Associa- fied by severity of presentation. Eti- There were no differences for the hort study. tion of cardiac rehabilitation with ology of the AC was inconsistently primary outcome of quality-ad- SETTING: Enrolled Medicare benefi- decreased hospitalization and mor- reported amongst studies. justed life-years or the secondary ciaries residing in the United States tality risk after cardiac valve sur- BOTTOM LINE: Emergent ERCP outcome of depression-free days in 2014. gery. JAMA Cardiol. 2019 Oct 23. doi: appears to be associated with re- between groups. Additionally, there SYNOPSIS: There were 41,369 Medi- 10.1001/jamacardio.2019.4032. duced mortality and LOS in patients was no difference in mortality or care patients who underwent CVS presenting with AC, though larger patient-reported harms of screening and met the study requirements; Emergent ERCP in acute randomized controlled trials are between groups. The study excluded of these, 43.2% enrolled in CR pro- 2 cholangitis linked with needed to better delineate the op- patients who already had a history grams. Those who had concomitant better outcomes timal timing for biliary drainage in of depression, psychiatric history, coronary artery bypass grafting these patients. or other severe life-threatening (CABG) surgery or who resided in CLINICAL QUESTION: Are out- CITATION: Iqbal U et al. Emergent medical conditions, which may have the Midwest region of the United comes better for patients with acute versus urgent ERCP in acute cholan- affected the outcomes. States were more likely to enroll cholangitis (AC) if endoscopic ret- gitis: A systematic review and meta- Depression remains a substantial in CR. Asian, black, and Hispanic rograde cholangiopancreatography analysis. Gastrointes Endosc. 2019 factor in coronary disease and qual- patients were less likely to enroll (ERCP) is done emergently (within Oct 16. doi: 10.1016/j.gie.2019.09.040. ity of life; however, systematic de- in CR. Enrollment in CR after CVS 48 hours) versus urgently (more Dr. Babbel is a hospitalist and pression screening appears to have was associated with a decreased than 48 hours)? assistant professor of medicine at the limited population-level benefits. risk of 1-year hospitalization (hazard BACKGROUND: AC in its most University of Utah, Salt Lake City. BOTTOM LINE: Systematic de- ratio, 0.66; 95% confidence interval, severe form is associated with a pression screening with or without 0.63-0.69). CR utilization was also high mortality rate. Most patients By Claire Ciarkowski, MD treatment offerings did not alter associated with a decrease in 1-year respond to medical management Depression screening quality of life, depression-free days, mortality after CVS (HR, 0.39; 95% involving intravenous hydration 3 after ACS does not change or mortality in patients with ACS. CI, 0.35-0.44). and antibiotics, though a sizable outcomes CITATION: Kronish IM et al. Effect Enrollment rates in CR after portion require biliary drainage. of depression screening after acute CVS were lower than that of heart Current guidelines advocate for ur- CLINICAL QUESTION: Does system- coronary syndrome on quality of life. transplant patients, but higher than gent drainage depending on the se- atic screening for depression in acute JAMA Intern Med. 2020;180(1):45-53. February 2020 | 16 | The Hospitalist

16thru20_HOSP20_02.indd 16 1/22/20 2:44 PM Family-involved proved indication for dapagliflozin alternative indication for beta- fidence interval, 1.20-2.83). These 4 interventions reduce (Farxiga)? blocker use? were defined as exacerbations postoperative delirium BACKGROUND: Dapagliflozin is a BACKGROUND: Beta-blockers are requiring hospitalization and me- selective inhibitor of sodium-glu- underutilized in patients with both chanical ventilation, respectively. CLINICAL QUESTION: Is the Tai- cose transporter 2 (SGLT2) in the COPD and established cardiovas- Importantly, this trial excluded lored, Family-Involved Hospital El- kidney; the drug blocks glucose re- cular indications for beta-blocker patients with established indica- der Life Program (t-HELP) effective absorption in the proximal tubule. therapy, despite evidence suggesting tions for beta-blocker therapy, and in reducing the incidence of postop- It is taken once daily by mouth. overall benefit. Prior observational study findings should not be applied erative delirium (POD) in older pa- An initial study sponsored by As- studies have associated beta-block- to this population. tients after noncardiac surgery? traZeneca was published January ers with improved outcomes in BOTTOM LINE: Metoprolol is not as- BACKGROUND: Postoperative de- 2019 in the New England Journal COPD in the absence of cardiovas- sociated with increased risk of COPD lirium is common in older patients of Medicine – “Dapagliflozin and cular indications; however, this has exacerbations, but is associated with undergoing surgery and often leads cardiovascular outcomes in type 2 not been previously evaluated in a increased severity of COPD exacer- to complications including longer diabetes.” Until recently there was randomized trial. bations in patients with moderate length of stay (LOS), increased not an FDA-approved indication for STUDY DESIGN: Placebo-controlled, to severe COPD who have no estab- mortality, functional decline, and the drug. double-blind, prospective, random- lished indications for beta-blockers. dementia. The volunteer-based Hos- STUDY DESIGN: Randomized, dou- ized trial. CITATION: Dransfield MT et al. Me- pital Elder Life Program (HELP) is ble-blind, placebo-controlled trial. SETTING: A total of 26 centers in the toprolol for the prevention of acute one of the most widely implemented SETTING: 882 United States. exacerbations of COPD. N Engl J prevention tools to reduce POD; how- clinical sites in 33 SYNOPSIS: The BLOCK COPD Med. 2019 Oct 20. doi: 10.1056/NEJ- ever, different cultures may not use countries. trial randomized more than 500 Moa1908142. volunteers in their hospital systems. SYNOPSIS: The patients with moderate to severe STUDY DESIGN: Randomized clini- study randomized COPD and no established indica- In-hospital mobility cal trial. approximately tion for beta-blocker therapy to 7 impairment in older MI SETTING: West China Hospital in 17,000 patients extended-release metoprolol or patients predicts postdischarge Chengdu. to receive either placebo. There was no significant functional decline SYNOPSIS: This Chinese-based dapagliflozin or difference in the primary endpoint clinical trial evaluated 281 patients Dr. Como placebo in addition of time until first exacerbation. CLINICAL QUESTION: Does in-hos- aged 70 years or older who under- to any other dia- While there was no difference in pital mobility of older patients went elective surgery and were ran- betes treatments prescribed by their the overall risk of exacerbations hospitalized for acute myocardial domized to either t-HELP units or physician. This study demonstrated of COPD, the trial was terminated infarction predict overall functional usual-care units. t-HELP patients re- its primary safety outcome, which early because of increased risk of decline after discharge? ceived three universal protocols that was that patients on dapagliflozin did severe or very severe exacerba- BACKGROUND: The ability to inde- included family-driven interventions not have any more major adverse car- tions of COPD in the metoprolol pendently perform daily activities of orientation, therapeutic activities, diac events (MACE), compared with group (hazard ratio, 1.91; 95% con- Continued on following page and early mobilization protocols, as placebo. There were two primary well as targeted protocols based on efficacy outcomes. First, there was no delirium risk factors, while control change in MACE with dapagliflozin, participants received usual nursing compared with placebo. Second, and care. The incidence of POD was pertinent to this drug’s approval, was significantly reduced in the t-HELP that dapagliflozin reduced risk of hos- group, compared with the control pitalization for heart failure (HF) from group (2.6% vs. 19.4%), which was 5.8% to 4.9%, compared to placebo; also associated with a shorter LOS. this includes both HF with both pre- Patients were also noted to have served and reduced ejection fractions. less cognitive and functional decline BOTTOM LINE: Dapagliflozin now that was sustained after discharge. has an FDA-approved indication to BOTTOM LINE: For hospitals that reduce hospitalizations for HF in do not use volunteers in delirium patients with type 2 diabetes. Based prevention, involving family appears on this study, the number needed to to be effective in reducing POD and treat with dapagliflozin is 111 patients maintaining physical and cognitive to prevent one hospitalization for HF. Time is running out to function post operatively. CITATION: Farxiga approved in the CITATION: Wang YY et al. Effect of US to reduce the risk of hospital- participate in the 2020 State of the Tailored, Family-Involved Hospi- ization for heart failure in patients tal Elder Life Program on postoper- with type-2 diabetes. AstraZeneca Hospital Medicine Survey. ative delirium and function in older Press Release, 2019 Oct 21. adults: A randomized clinical trial. Dr. Como is a hospitalist and Submit your group’s data by February 16th to be JAMA Intern Med. 2019 Oct 21. doi: clinical instructor of medicine at the 10.1001/jamainternmed.2019.4446. University of Utah, Salt Lake City. represented in the nation’s only report dedicated Dr. Ciarkowski is a hospitalist and to the hospital medicine specialty. clinical instructor of medicine at the By John Gerstenberger, MD University of Utah, Salt Lake City. Metoprolol increases Participate at severity, but not risk, of 6 hospitalmedicine.org/2020survey By Natalie Como, MD COPD exacerbations Dapagliflozin may cut risk 5 of HF hospitalization in CLINICAL QUESTION: Does me- patients with type 2 diabetes toprolol affect time until exacerbation in patients with moderate CLINICAL QUESTION: What is the to severe chronic obstructive pul- Food and Drug Administration–ap- monary disease (COPD) without an the-hospitalist.org | 17 | February 2020

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Continued from previous page with an adjusted odds ratio of 5.45 most up-to-date, evidence-based rec- Short Takes is highly valued by patients, yet it is (95% confidence interval, 3.29-9.01). ommendations for the diagnosis and commonly impaired in older adults While in-hospital mobility is pre- treatment of community-acquired Dual-antiplatelet therapy after hospitalization for MI. Risk of dictive of future functional decline pneumonia (CAP)? reduces graft failure after functional decline in this population in this population, this observation- BACKGROUND: More than a de- CABG is not well understood, but may al study cannot establish whether cade has passed since the last CAP Network meta-analysis found relate to reduced mobility while hos- attempts to improve mobility in guidelines. Since then there have that dual-antiplatelet therapy pitalized. hospitalized patients will prevent been new trials and epidemiolog- (aspirin with either clopidogrel STUDY DESIGN: Prospective cohort. future functional decline. ical studies. There have also been or ticagrelor) was superior to SETTING: A total of 94 academic BOTTOM LINE: Lower performance changes to the process for guideline aspirin alone in maintaining and community hospitals in the on the Timed “Up and Go” test of development. This guideline has saphenous vein graft patency United States. mobility among older patients hos- moved away from the narrative after coronary artery bypass SYNOPSIS: More than 3,000 adults pitalized for MI is associated with style of guidelines to the GRADE graft surgery. No significant aged 75 years and older who were functional decline 6 months after format and PICO framework with differences were found in rates hospitalized for acute myocardial hospitalization. hopes of answering specific ques- of major bleeding, myocardial infarction were enrolled in the pro- CITATION: Hajduk AM et al. Asso- tions by looking at the quality of infarction, and death. spective cohort SILVER-AMI; 2,587 ciation between mobility measured evidence. CITATION: Solo K et al. patients within this cohort were during hospitalization and func- STUDY DESIGN: Multidisciplinary Antithrombotic treatment after evaluated for in-hospital mobility tional outcomes in older adults with panel conducted pragmatic sys- coronary artery bypass graft with the Timed “Up and Go” test. acute myocardial infarction in the temic reviews of high-quality stud- surgery: Systemic review and At 6-month follow-up, loss of inde- SILVER-AMI study. JAMA Intern ies. network meta-analysis. BMJ. pendent performance of activities Med. 2019 Oct 7. doi: 10.1001/jamaint- SETTING: The panel revised and 2019;367:I5476. of daily living (ADL) and of the ernmed.2019.4114. built upon the 2007 guidelines, ad- ability to walk Dr. Gerstenberger is a hospitalist dressing 16 clinical questions to be 0.25 miles were and clinical assistant professor of used in immunocompetent patients CITATION: Metlay JP et al. Diag- both associated medicine at the University of Utah, with radiographic evidence of CAP nosis and treatment of adults with in a dose-depen- Salt Lake City. in the United States with no recent community-acquired pneumonia: dent manner foreign travel. An official clinical practice guideline with in-hospital By Devin Horton, MD SYNOPSIS: Changes from the 2007 of the American Thoracic Society mobility. Severe New guidelines on the guidelines are as follows: Sputum and Infectious Diseases Society of in-hospital mo- 8 diagnosis and treatment of and blood cultures, previously rec- America. Am J Respir Crit Care Med. bility impairment adults with CAP ommended only in patients with 2019 Oct 1;200(7):e45-67. Dr. Gersten- was associated severe CAP, are now also recom- berger with ADL decline CLINICAL QUESTION: What are the mended for inpatients being empir- PCI and CABG for left ically treated for Pseudomonas or 9 main disease have equal methicillin-resistant Staphylococ- outcomes at 5 years cus aureus (MRSA) and for those who have received IV antibiotics CLINICAL QUESTION: In a patient in the previous 90 days; use of with left main coronary disease, is procalcitonin is not recommend- percutaneous coronary intervention ed to decide whether to withhold (PCI) or coronary artery bypass graft- antibiotics; steroids are not rec- ing (CABG) a better option when con- ommended unless being used for sidering long-term (5-year) outcomes? shock; HCAP categorization should BACKGROUND: While PCI with be abandoned and need for empiric drug-eluting stents has become SHM provides hospital-based coverage of MRSA and Pseudo- more accepted as treatment for providers with a platform to learn monas should be based on local some patients with left main dis- epidemiology and local validated from, network through and make ease, long-term outcomes from ran- risk factors; B-lactam/macrolide is domized control trials comparing our voices and needs heard. favored over fluoroquinolone for PCI with CABG have yet to be clear- severe CAP therapy; and routine ly established. Suj Sundararaj, MD, MBA follow-up chest x-ray is not recom- STUDY DESIGN: International, mended. open-label, multicenter, randomized Other recommendations include trial. not routinely testing for urine SETTING: A total of 126 sites in 17 pneumococcal or legionella antigens countries. If I had one regret, it’s not joining as soon as in nonsevere CAP; using PSI over SYNOPSIS: Patients with low or CURB-65, in addition to clinical judg- intermediate anatomical complexity I became a hospitalist. ment, to determine need for inpa- with 70% visual stenosis of the left Ilya Yepishin, DO tient care; using severe CAP criteria main coronary artery or 50%-70% and clinical judgment for determin- stenosis by noninvasive testing were ing ICU need; not adding anaerobic randomized to either PCI (948) or coverage for aspiration pneumonia; CABG (957). Dual-antiplatelet ther- and treating most cases of CAP that apy was given to PCI patients and are clinically stable and uncompli- aspirin to CABG patients. At 5 years Our focus is your future. cated for 5-7 days. there was no significant difference Not a member? Don’t wait. BOTTOM LINE: Given new data, in the rate of the composite of death, Join today at hospitalmedicine.org/join updated recommendations have stroke, or myocardial infarction been made to help optimize CAP (22.0% with PCI vs. 19.2% with CABG; therapy. difference, 2.8 percentage points; 95% February 2020 | 18 | The Hospitalist

16thru20_HOSP20_02.indd 18 1/22/20 2:44 PM CLINICAL | In the Literature

CI, –0.9 to 6.5; P = .13). This was con- 245,048 patients had their CVD apolis; Washington County, Md.; and disease, the atherosclerosis risk in sistent across subgroups. risk assessed and did not meet Forsyth County, N.C. communities study. JAMA Cardiol. There were numerical differences exclusion criteria. The online tool SYNOPSIS: Among a large cohort of 2019 Oct 9;4(12):1203-12. in nonpowered secondary outcomes predicts CVD events avoided and community-dwelling middle-aged Dr. Rupp is a hospitalist and clinical that may represent effects but bleeding events caused by aspirin. adults, this study showed that neg- instructor of medicine at the should be interpreted cautiously: When one CVD event was equiva- ative income changes are associated University of Utah, Salt Lake City. ischemia-driven revascularization lent to one major bleeding event, with an increased incidence of CVD. (16.9% with PCI vs. 10% with CABG), 2.5% of women and 12.1% of men Among 8,989 patients recruited from Note: Dr. LaBrin is an associate pro- transient isch- were classified as benefiting from the four urban centers above, 10% fessor of medicine at the University emic attack plus aspirin (more CVD events avoided experienced an income drop, 70% of Utah. He edited and assisted the stroke (3.3% with than bleeding events caused). When did not have a change in income, authors with the reviews. PCI vs. 5.2% with one CVD event was equivalent to and 20% experienced an income CABG), and death two major bleeding events, 21.4% increase over the first 6 years of the Short Takes from any cause of women and 40.7% of men were study. Patients were followed for (3% with PCI vs. classified as benefiting from as- a mean of 17 years, and those who 9.9% with CABG). pirin. The net-benefit subgroups experienced an income drop were Rivaroxaban versus There was no were older, and had higher baseline found to have a 17% higher risk of vitamin K antagonist in Dr. Horton significant differ- 5-year CVD risk, fewer risk factors incident CVD, whereas those who antiphospholipid syndrome ence in cardiovas- for bleeding, higher systolic blood experienced an income increase had In a randomized noninferiority cular events, MI, or stroke. pressure, and a higher total choles- a 14% lower risk of CVD. trial, rivaroxaban did not show One interesting limitation was terol to HDL cholesterol ratio. Eth- The study was limited by diffi- noninferiority to vitamin K antag- that patients who had PCI were nicity and socioeconomic index also culties classifying income and its onists in the secondary preven- more commonly on dual-antiplate- influenced benefit or harm. changes; the complicated nature tion of thrombosis in antiphos- let therapy and angiotensin con- With use of the upper and lower of income, its relationship with pholipid syndrome. Recurrent verting–enzyme inhibitors, whereas limits of 95% confidence intervals other socioeconomic factors, and thrombosis occurred in 11.6% of CABG patients were more often on for models, there were consid- causation inferences; and the rel- the rivaroxaban group and 6.3% beta-blockers, diuretics, anticoagu- erable ranges of benefit versus atively short span over which in- of the vitamin K antagonist group lants, and antiarrhythmics. harm. Sex-specific risk scores and come was monitored. (not statistically significant). BOTTOM LINE: PCI and CABG meta-analysis have intrinsic uncer- BOTTOM LINE: Income decrease is CITATION: Ordi-Ros J et al. treatments for left main disease tainties and results potentially not associated with an increased risk of Rivaroxaban versus vitamin K have no significant difference in the generalizable outside New Zealand incident CVD. antagonist in antiphospholip- composite outcome of death, stroke, population. Ultimate decision to CITATION: Wang S et al. Longitu- id syndrome. Ann Intern Med. or MI at 5 years. use aspirin requires shared decision dinal associations between income 2019;171(8):685-94. CITATION: Stone GW et al. Five-year making. changes and incident cardiovascular outcomes after PCI or CABG for BOTTOM LINE: Some patients are left main coronary disease. N Engl J likely to derive a net benefit from Med. 2019;381:1820-30. aspirin for primary prevention of Dr. Horton is a hospitalist and CVD. Risk-benefit models with on- clinical instructor of medicine at the line tools can help providers and University of Utah, Salt Lake City. patients estimate these factors to inform shared decision making. By Austin Rupp, MD CITATION: Selak V et al. Personal- The role of aspirin in ized prediction of cardiovascular 10 primary prevention of benefits and bleeding harms for as- cardiovascular disease pirin for primary prevention, a ben- Advance your research and efit-harm analysis. Ann Intern Med. CLINICAL QUESTION: Does aspirin 2019;71(8):529-39. quality improvement objectives have a role in primary prevention of cardiovascular disease? Longitudinal associations BACKGROUND: Previous studies 11 between income changes Partner with SHM’s Center for have shown that aspirin reduces and incident CVD the relative risk of cardiovascular Quality Improvement disease (CVD) but also increases the CLINICAL QUESTION: Is there relative risk of bleeding. It is unclear an association between income SHM can provide you with key support to facilitate if there are patients without known change and cardiovascular disease grant objectives, including: CVD in whom the absolute risk (CVD)? reduction of CVD outweighs the BACKGROUND: Low income is absolute risk of bleeding. Prognostic associated with CVD, although Day-to-day project Educational resource Site recruitment and Research dissemination CVD and bleeding risk models allow causality remains debated because management and development coordination implementation support for an assessment of absolute risks low income is also associated with for study sites and primary preventive interven- depression and negative health tions. behaviors, which can be associated STUDY DESIGN: Individualized with CVD. For more robust causal Contact Jenna Goldstein at [email protected] for more information. risk-benefit analysis based on inference, changes in income and sex-specific risk scores and esti- their association with CVD must be mates from PREDICT cohort data. observed. SETTING: Primary care practices in STUDY DESIGN: Prospective obser- hospitalmedicine.org/QI New Zealand. vational cohort study. ® SYNOPSIS: Using the New Zea- SETTING: Four U.S. urban centers land–based PREDICT online tool, – Jackson, Miss.; suburbs of Minne- the-hospitalist.org | 19 | February 2020

16thru20_HOSP20_02.indd 19 1/22/20 2:44 PM Make your next smart move. Visit shmcareercenter.org.

supporting our faculty, The Ohio State University Wexner Medical Center so they can focus on what really matters Join a Leader in Hospital Medicine Joy. As one of the nation’s largest academic hospitalist programs, we lead a variety of teaching and non- Make it part of your career. teaching inpatient and consultative services. Our Faculty Enjoy: OSUWMC Division of Hospital Medicine is dedicated Competitive salary & bonus to the health and well-being of our patients, team including a rich benefit Vituity provides the support and resources members, and our OSUWMC community. Our package you need to focus on the joy of healing. mission is to improve the lives of our patients and Manageable clinical We currently have opportunities for hospitalists and faculty by providing personalized, patient-centered, workload with flexible intensivists at hospitals and skilled nursing practices across evidence-based medical care of the highest quality. scheduling options Faculty appointment the country. Some with sign-on bonuses up to $100,000! Our clinical practice meets rigorous standards of commensurate with scholarship, and we are devoted to serving as expert experience educators and mentors to the next generation of Opportunities for leadership physicians. & professional development, research & quality Preferred candidates are BC/BE in Internal Medicine improvement, and resident or Internal Medicine-Pediatrics, have work and medical student experience or residency training at an academic teaching in partnership with the College of Medicine medical center, and possess excellent inpatient, http://go.osu.edu/hospitalmedicine Robust onboarding and teamwork, and clinical skills. mentoring program Ongoing education and OSUWMC is an equal opportunity/affirmative action development programs employer and encourages applications from women Relocation allowance and minorities. This is not a J-1 opportunity. Sign on bonus

University Hospital Richard M. Ross Heart Hospital NOW INTERVIEWING COMPETITIVE APPLICANTS University Hospital East Dodd Rehabilitation Hospital James Cancer Hospital & OSU Harding Hospital [email protected] Solove Research Institute Nationwide Children's Hospital (Med-Peds)

Classified Advertising—FIND THE PERFECT FIT! For more information on placing your classified advertisement in the next available issue, contact: Heather Gonroski • 973.290.8259 • [email protected] Linda Wilson • 973.290.8243 • [email protected]

California • Fresno • Redding • San Jose • Modesto • San Diego • San Mateo Find your next job today! Illinois Missouri Oregon • Belleville • St. Louis • Eugene visit SHMCAREERCENTER.ORG • Greenville

Interested in travel? Check out our Reserves Program.

Future leader? Apply for our Administrative Fellowship.

We proudly sponsor visa candidates!

For more information, please contact us at [email protected].

February 2020 | 20 | The Hospitalist Make your next smart move. Visit shmcareercenter.org.

Hospitalist Opportunities Gorgeous Lakes, Ideal Climate, Award-winning Downtown I nspire health. Serve with compassion. Be the difference.

Prisma Health-Upstate employs 16,000 people, including 1,200+ physicians on staff. Our system includes clinically excellent facilities with 1,627 beds across 8 campuses. Additionally, we host 19 residency and fellowship programs and a 4-year medical education program: University of South Carolina School of Medicine–Greenville, located on Prisma Health-Upstate’s Greenville Memorial Medical Campus. Prisma Health-Upstate also has developed a unique Clinical University model in collaboration with the University of South Carolina, Clemson University, Furman University, and others to provide the academic and research infrastructure and support needed to become a leading academic health center for the 21st century. Greenville, South Carolina is a beautiful place to live and work and is located on the I-85 corridor between Atlanta and Charlotte and is one of the fastest growing areas in the country. Ideally situated near beautiful mountain ranges, beaches and lakes, we enjoy a diverse and thriving economy, excellent quality of life and wonderful cultural and educational opportunities. Check out all that Greenville, SC has to offer! #yeahTHATgreenville

Ideal Candidates: • BC/ BE I nternal Medicine P hysicians • IM procedures highly desired, but not required. Simulation center training & bedside training available if needed. • Comfort managing critically ill patients. Details Include: • G roup comprised of career hospitalists with low turnover • R elocation allowance available • EP I C Electronic Medical R ecord system • 7 on/7 off schedule with 1 week of vacation per year • Additional shifts paid at a premium Available Opportunities: Nocturnist, G reenville Memorial Hospital • $ 34 0K base salary with $ 10K incentive bonus and CME stipend • Up to $ 4 0K sign on bonus • Minimum of 3 physician night coverage team • Academic appointment and resident supervision opportunity • Codes run by critical care team • Full subspecialist back up Nocturnist or Traditional Hospitalist, Baptist Easley Hospital • $ 24 0-260K base salary with 4 5K incentive bonus and CME stipend for Traditional Hospitalist • $ 320K base salary with $ 10K incentive bonus and CME stipend for Nocturnist • Up to $ 4 0K sign on bonus for Nocturnist Med- P eds Hospitalist or Nocturnist, G reer Memorial Hospital • BC/BE in internal medicine-pediatrics • $ 290K base salary with $ 4 5K incentive bonus and CME stipend for Med – P eds Hospitalist • $ 34 0K base salary with $ 10K incentive bonus and CME stipend for Med – P eds Nocturnist • Up to $ 4 0K sign on bonus • Adult and pediatric specialist support in house or by phone • Comfortable with I M procedures and managing critically ill patients

*Public Service Loan Forgiveness (PSLF) Program Qualified Employer* Please submit a letter of interest and CV to: Natasha Durham, Physician Recruiter, [email protected], ph: 864-797-6114

the-hospitalist.org | 21 | February 2020 Make your next smart move. Visit shmcareercenter.org.

Hospitalist Opportunities with Penn State Health

Penn State Health is a multi-hospital health system serving patients and communities across central Pennsylvania. We are seeking hospitalists and nocturnists interested in joining the Penn State Health family in various settings within our system. What We’re Offering: • Academic Hospitalist and Nocturnist positions (Hershey, PA) • Community Setting Hospitalist opportunities (Lancaster and Berks County positions) • We’ll foster your passion for patient care and cultivate a collaborative environment rich with diversity • Commitment to patient safety in a team approach model • Experienced hospitalist colleagues and collaborative leadership • Salary commensurate with qualifications • Relocation Assistance What We’re Seeking: • Completion of an accredited training program • Ability to acquire license in the State of Pennsylvania • Must be able to obtain valid federal and state narcotics certificates. • Current American Heart Association BLS and ACLS certification required. • BE/BC in Family Medicine or Internal Medicine (position dependent) No J1 visa waiver sponsorships available What the Area Offers: Penn State Health is located in Central Pennsylvania. Our local neighborhoods boast a reasonable cost of living whether you prefer a more suburban setting or thriving city rich in theater, arts, and culture. Our surrounding communities are rich in history and offer an abundant range of outdoor activities, arts, and diverse experiences. We’re conveniently located within a short distance to major cities such as Philadelphia, Pittsburgh, NYC, Baltimore, and Washington DC. For more information please contact: Heather J. Peffley, PHR FASPR, Penn State Health Physician Recruiter [email protected] Penn State Health is committed to affirmative action, equal opportunity and the diversity of its workforce. Equal Opportunity Employer – Minorities/Women/Protected Veterans/Disabled.

Employment Opportunity in the Beautiful Where Quality of Life and Quality of Care Come Together Adirondack Mountains of Northern New York Hospitalist Opportunities Available Current Opening for a full-time, The Berkshires ~ Hospital Employed Hospitalist. This opportunity Western Massachusetts provides a comfortable 7 on/7 off schedule, allowing ample time to enjoy all that the Berkshire Health Systems is currently seeking BC/BE Internal Adirondacks have to offer! Medicine & Med/Peds physicians to join our comprehensive Hospitalist Department Come live where others vacation! • Day, Evening and Nocturnist positions • 7 on/7 of f 10 hour shif t schedule • Convenient schedules • Previous Hospitalist experience is pref erred • Competitive salary & benefits Located in Western Massachusetts Berkshire Medical Center is the • Unparalleled quality of life • Family friendly community region’s leading provider of comprehensive health care services • Excellent schools • 302-bed community teaching hospital • Nearby Whiteface • A maj or teaching af f iliate of the U niversity of Mountain ski resort Massachusetts Medical School • Home of the 1932 & 1980 • The latest technology including a system-w ide electronic health record To advertise in Winter Olympics and current Olympic Training Center • A closed ICU /CCU The Hospitalist or the • Annual lronman Competition • A f ull spectrum of Specialties to support the team. Journal of Hospital Medicine • World Cup Bobsled and We understand the importance of balancing work with a healthy Ski Events personal lifestyle • Abundant arts community • Located j ust 2½ hours f rom Boston and New York City Hike, fish, ski, golf, boat or simply relax • Small tow n New England charm CONTACT: and take in the beauty and serenity of • Excellent public and private schools the Adirondack Mountains • World renow ned music, art, theater, and museums Heather Gonroski • Year round recreational activities f rom skiing to kayaking, 973.290.8259 Contact: Joanne Johnson this is an ideal f amily location. [email protected] 518-897-2706 Berkshire Health Systems offers a competitive salary and benefits [email protected] or www.adirondackhealth.org package, including relocation. Linda Wilson Interested candidates are invited to contact: 973.290.8243 Liz Mahan • (413) 39 5-7866 [email protected] [email protected] Apply online at: www.berkshirehealthsystems.org

February 2020 | 22 | The Hospitalist Make your next smart move. Visit shmcareercenter.org.

DIVISION CHIEF, HOSPITALIST MEDICINE DEPARTMENT OF MEDICINE Hershey, Pennsylvania

Penn State Health Milton S. Hershey Medical Center invites applications and nominations for the position of Division Chief, Hospitalist Medicine. The successful candidate will be a nationally recognized academic leader with a substantial record of leadership, clinical and administrative accomplishments, education scholarship and/or research productivity and teaching experience. We seek candidates with prior administrative and leadership experience gained within a Department of Medicine, strong interpersonal and communication skills and demonstrated ability to effectively inspire, manage, mentor, and develop faculty and staff. Candidates must hold the degree of MD, DO, or equivalent, or MD/PhD, be board certiﬁed in internal medicine, and possess qualiﬁcations for appointment.

The Division of Hospital Medicine at Penn State Health is made up of ﬁve teaching teams, ﬁve attending teams, two nocturnists, one consult team and one triage team. Together they provide inpatient care to 140+ hospitalized patients per day. The discipline of hospital medicine grew out of the increasing complexity of patients requiring hospital care and the need for dedicated clinicians to oversee their care. There are plans to further expand the number of providers, presenting a tremendous opportunity for a visionary leader to establish a national presence.

INQUIRIES, NOMINATIONS AND EXPRESSIONS OF INTEREST, INCLUDING A CURRICULUM VITAE AND COVER LETTER, SHOULD BE SUBMITTED CONFIDENTIALLY VIA EMAIL TO Heather Pefﬂey, PHR FASPR: hpefﬂ[email protected].

Penn State Health is committed to afﬁrmative action, equal opportunity and the diversity of its workforce. Equal Opportunity Employer – Minorities/Women/Protected Veterans/Disabled.

the-hospitalist.org | 23 | February 2020 Make your next smart move. Visit shmcareercenter.org.

Hospitalist & Nocturnist Opportunities in SW Virginia & NE Tennessee

Ballad Health, located in Southwest Virginia and Northeast Tennessee, is Full time positions with the following incentives: currently seeking Full Time, BE/BC, Day Shift Hospitalists and Nocturnist  Hospitalists to join its team. Hospital Employed (earning potential, exceeding $300K per year)  Day and Nocturnist Shifts (7 days on – 7 days off) Qualified candidates will work within Ballad Health Facilities and will need  Competitive Annual Salary an active Virginia and/or Tennessee license, depending on facility location.  Performance Bonus & Production Bonus  Excellent Benefits  Generous Sign On Bonus Facilities:  Relocation Assistance Ballad Health Southwest Virginia  Teaching and Faculty Opportunities with System Residency Programs Johnston Memorial Hospital, Russell County Medical Center, Smyth County  Critical Care Physician Coverage in most of the facilities CCU/PCUs Community Hospital, Norton Community Hospital, Mountain View Regional  Opportunity to Participate in Award-Winning Quality Improvement Projects Medical Center, Lonesome Pine Hospital

Ballad Health Northeast Tennessee Johnson City Medical Center, Holston Valley Medical Center, Bristol Regional Medical Center and Hawkins County Memorial Hospital

Please Contact: Tina McLaughlin, CMSR Ballad Health Senior Physician Recruiter O) 276-258-4580 [email protected]

HOSPITALIST & NOCTURNIST OPPORTUNITIES DENVER, COLORADO Currently seeking qualified Medicine Nocturnists for Midtown Inpatient Medicine, LLC, located in Denver, Colorado. MiM is a physician-owned, physician-run company with local leadership, flexible scheduling, competitive compensation and a balanced, positive culture of work. We offer partnership opportunities, an excellent benefit package including health, dental, CME, 401K, malpractice, credentialing and administrative support, and reimbursement and bonuses that emphasize quality in To advertise in healthcare. The Hospitalist or the Denver is nestled at the foot of the Rocky Journal of Hospital Medicine Mountains, with vibrant arts and restaurant options, major sports teams, nearby skiing CONTACT: and hiking, great schools and over 300 days of sunshine every year. Heather Gonroski Linda Wilson Please email your CV to: 973.290.8259 or 973.290.8243 [email protected] [email protected] [email protected]

February 2020 | 24 | The Hospitalist Make your next smart move. Visit shmcareercenter.org.

HOSPITALISTS/ NOCTURNISTS NEEDED IN SOUTHEAST LOUISIANA

HOSPITALIST Ochsner Health System is seeking physicians to join our FULL TIME hospitalist team. BC/BE Internal Medicine and Family Medicine NASSAU COUNTY, LONG ISLAND physicians are welcomed to apply. Highlights of our opportunities are: NASSAU UNIVERSITY MEDICAL CENTER  Hospital Medicine was established at Ochsner in 1992. We have a stable 50+ member East Meadow, LI, NY. With a strong commitment group to raising the bar for healthcare in our community, Nassau University Medical Center is a Level I Trauma  7 on 7 off block schedule with flexibility Center and a 530-bed teaching hospital afﬁliated with  Dedicated nocturnists cover nights Northwell Health and Stony Brook University. We are a full-service community hospital located just 30 miles  Base plus up to 40K in incentives from New York City.  Average census of 14-18 patients

NUMC is looking for an Internal Medicine Hospitalist  E-ICU intensivist support with open ICUs at the community hospitals to join our team. Board certiﬁcation in Internal  EPIC medical record system with remote access capabilities Medicine required.  Dedicated RN and Social Work Clinical Care Coordinators We offer exceptional beneﬁts including medical, dental, pension and much more!  Community based academic appointment  The only Louisiana Hospital recognized by US News and World Report Distinguished For immediate consideration please Hospital for Clinical Excellence award in 3 medical specialties forward CV and a letter of interest to:  Co-hosts of the annual Southern Hospital Medicine Conference [email protected]  We are a medical school in partnership with the University of Queensland providing clinical training to third and fourth year students WWW.NUMC.EDU AN EOE M/F/D/V  Leadership support focused on professional development, quality improvement, and academic committees & projects  Opportunities for leadership development, research, resident and medical student teaching  Skilled nursing and long term acute care facilities seeking hospitalists and mid-levels with Hospitalist/Nocturnist an interest in geriatrics Cambridge Health Alliance (CHA)  Paid malpractice coverage and a favorable malpractice environment in Louisiana Cambridge Health Alliance (CHA), a well-respected, nationally recognized and award-winning public healthcare system, is  Generous compensation and benefits package recruiting for part time and full time hospitalists and nocturnists. CHA is a teaching affiliate of both Harvard Medical School (HMS) Ochsner Health System is Louisiana’s largest non-profit, academic, healthcare system. and Tufts University School of Medicine. Our system is comprised Driven by a mission to Serve, Heal, Lead, Educate and Innovate, coordinated clinical and of three campuses and an integrated network of both primary and hospital patient care is provided across the region by Ochsner’s 40 owned, managed and specialty outpatient care practices in Cambridge, Somerville and affiliated hospitals and more than 100 health centers and urgent care centers. Ochsner is the Boston’s Metro North Region. only Louisiana hospital recognized by U.S. News & World Report as a “Best Hospital” across • Full time and part time opportunities available three specialty categories caring for patients from all 50 states and more than 70 countries • Schedule will consist of daytime and nighttime shifts, worldwide each year. Ochsner employs more than 25,000 employees and over 4,500 nocturnist positions are available employed and affiliated physicians in over 90 medical specialties and subspecialties, and • Academic Appointment at Harvard Medical School conducts more than 700 clinical research studies. For more information, please visit • Opportunity to teach medical students and residents ochsner.org and follow us on Twitter and Facebook. • Two coverage locations approximately 5 miles apart • Physician assistant support at both locations Interested physicians should click here to apply online. • CHA’s hospitalist department consists of 25+ clinicians Ideal candidates will be Board Certified, patient centered and Visit ochsner.org/physician Job Number 00022186 demonstrate a strong commitment to work with a multicultural, underserved patient population. Experience and interest in performing procedures and community ICU coverage preferred. At CHA we offer a supportive and collegial environment, a strong infrastructure, Sorry, no opportunities for J1 applications. a fully integrated electronic medical record system (EPIC) and com- Ochsner is an equal opportunity employer and all qualified applicants will receive consideration for petitive salary/benefits package. employment without regard to race, color, religion, sex, sexual orientation, gender identity, Please visit www.CHAproviders.org to learn more and apply through national origin, protected veteran status, or disability status. our secure candidate portal. CVs may be sent directly to Kasie Marchini at [email protected]. CHA’s Department of Provider Recruitment may be reached by phone at (617) 665-3555 or by fax at (617) 665-3553. We are an equal opportunity employer and all qualified applicants will To learn more, visit www.the-hospitalist.org and receive consideration for employment without regard to race, color, click “Advertise” or contact religion, sex, sexual orientation, gender identity, national origin, disability Heather Gonroski • 973-290-8259 • [email protected] or status, protected veteran status, or any other characteristic protected Linda Wilson • 973-290-8243 • [email protected] by law.

the-hospitalist.org | 25 | February 2020 PRACTICE MANAGEMENT Documentation matters Quality over quantity

By Erica Remer, MD, FACEP umentation is to clinically communicate to other caregivers. Think to yourself: “What would a ocumentation has always been part fellow clinician need to know about this patient of a physician’s job. Historically, in the to understand why I drew those conclusions days of paper records, physicians saw a or to pick up where I left off?” At 2 a.m., that patient on rounds and, immediately fol- information, or lack thereof, could literally be a Dlowing, while still on the unit, wrote a daily note matter of life or death. detailing the events, test results, and plans since • Tell the truth. Embellishing the record or in- the last note. Addenda were written over the cluding invalid diagnoses with the intent to in- course of the day and night as needed. crease the severity of illness resulting in a more The medical record was a chronological item- favorable diagnosis-related group – the inpatient ization of the encounter. The chart told the risk-adjustment system – is considered fraud. patient’s story, hopefully legibly and without • Consider doing a documentation time-out. You excessive rehashing of previous material. The may like the convenience of copy forward, but discharge summary then encapsulated the hospi- do you relish reading other people’s copy and talization in several coherent paragraphs. paste? Before you copy and paste yesterday’s as- In the current electronic records environment, sessment and plan, stop and think: “Why is the we are inundated with excessive and repetitious patient still here? Why are we doing what we information, data without interpretation, differ- are doing?” If you choose to copy and paste, be entials without diagnoses. Prepopulation of tem- certain to do mindful editing so the documenta- plated notes, defaults without edit, and dictation tion represents the current situation and avoids Dr. Remer was a practicing emergency physician without revision have degraded our documenta- redundancy. for 25 years and a physician advisor for 4 tion to the point of unintelligibility. The chrono- • Translate findings into diagnoses using your years. She is on the board of directors of the logical storytelling and trustworthiness of the best medical judgment. One man’s hypotension American College of Physician Advisors and the medical record has become suspect. may be another health care provider’s shock. advisory board of the Association of Clinical The Centers for Medicare & Medicaid Services Coders are not clinical and are not permitted to Documentation Improvement Specialists. is touting its “Patients over Paperwork” initiative. make inferences. A potassium of 6.7 may be hy- She currently provides consulting services for The solution is flawed (that is, future relaxation perkalemia or it may be spurious – only a clini- provider education on documentation, CDI, and of documentation requirements for professional cian may make that determination using their ICD-10 coding. Dr. Remer can be reached at billing) because the premise is delusive. Doc- clinical expertise and experience. The coder is [email protected] umentation isn’t fundamentally the problem. not allowed to read your mind. You must explic- Clinicians having to jump through regulatory itly draw the conclusion that a febrile patient hoops which do not advance patients’ care and with bacteremia, encephalopathy, hypoxemia, litus with diabetic chronic kidney disease, stage providers misunderstanding the requirements and a blood pressure of 85/60 is in septic shock. 4 does not equal chronic kidney disease; and L: for level-of-service billing are the essential issues. • Code uncertain diagnoses (heralded by words Linkage – of diagnosis with underlying cause or Getting no training on how to properly document such as: likely, possible, probable, suspected, manifestation [e.g., because of, associated with, in medical school/residency and receiving no rule out, etc.) which are not ruled out prior to as a result of, secondary to, or from diabetic ne- formative feedback on documentation through- discharge or demise as if they were definitively phropathy, hypertensive encephalopathy]). out one’s career compound the problem. Having present, for the inpatient technical side of hos- • If you have the capability to keep a running clinical documentation serve too many masters, pital billing. This is distinctly different than the summary throughout the hospital stay, do so including compliance, quality, medicolegal, utiliza- professional fee where you can code only defin- and keep it updated. A few moments of daily tion review, and reimbursement, is also to blame. itive diagnoses. If you have a strong suspicion careful editing and composing can save time and The advent of the electronic medical record was that a condition is present, best practice is to effort at the back end creating the discharge just the straw that broke the camel’s back. offer an uncertain diagnosis. Associate signs summary. Many hospitals now have a clinical documen- and symptoms with your most likely diagnosis: • Read your documentation over. Ensure that it tation integrity (CDI) team which is tasked with “Shortness of breath, pleuritic chest pain, and is clear, accurate, concise, and tells the story and querying the provider when the health record hypoxemia in the setting of cancer, probable the plans for the patient. documentation is conflicting, imprecise, incom- pulmonary embolism.” • Set up a program to self-audit documentation plete, illegible, ambiguous, or inconsistent. They • Evolve, resolve, remove, and recap. If an un- where monthly or quarterly, you and your are charged with getting practitioners to asso- certain diagnosis is ruled in, take away the partners mutually review a certain number of ciate clinical indicators with diagnoses and to uncertainty. If it is ruled out, don’t have 4 days records and give each other feedback. Design consider removal of diagnoses which do not seem of copy and pasted: “Possible eosinophilic pneu- an assessment tool which rates the quality of clinically valid from the existing documentation. monia.” You do not have to maintain a resolved documentation elements which your hospital/ From this explanation, you might well conclude diagnosis ad infinitum. It can drop off the diag- network/service line values (clarity, copy and that the CDI specialist could generate a query on nosis list but be sure to have it reappear in the paste, complete and specific diagnoses, etc.). every patient if they were so inclined, and you discharge summary. • Finally, answer CDI queries. The CDI specialist would be correct. But the goal isn’t to torture the • Realize it can be a hASSLe to do excellent doc- is your ally, not your enemy. They are not per- physician – it is to ensure that the medical record umentation, but it is critical for many reasons, mitted to lead the provider, so don’t ask them is accurately depicting the encounter. most importantly for superlative patient care. what they want you to write. But, if you don’t You are not being asked for more documenta- More accurate coding and billing is an intended understand the query or issue, have a conversa- tion by the CDI team; they are entreating you for consequence. (A: Acuity; S: Severity; S: Specific- tion and get it clarified. higher-quality documentation. Let me give you ity – may affect the coding and the risk-adjust- Documentation improves patient care and some pointers to ward off queries. ment implications. Acute systolic heart failure demonstrates that you provided excellent patient • Tell the story. The most important goal of doc- does not equal heart failure; type 2 diabetes mel- care. Put mentation back into documentation. February 2020 | 26 | The Hospitalist

26_27_HOSP20_02.indd 26 1/22/20 2:45 PM NEWS Transitional care offers no overall benefit But women respond more to intervention

By Richard Mark Kirkner said: all-cause death, readmissions, or MDedge News ED visits (63.1% and 64.5%, respectively; P = .50); or all-cause readmissions PHILADELPHIA – A clinical trial of a or ED visits (60.8% and 62.4%; P = .36). program that transitions heart fail- “Despite the mutual overall clini- ure patients after they’re discharged cal outcomes, we noted specific dif- from the hospital didn’t result in ferences in response to treatment,” any appreciable improvement in she said. With regard to the compos- all-cause death, readmissions, or ite endpoint that included all-cause emergency department visits after 6 death, “Men had an attenuated months overall, but it did show that response to the treatment with a women responded more favorably hazard ratio of 1.05 (95% confidence than men. interval, 0.87-1.26), whereas women Harriette G.C. Van Spall, MD, MPH, had a hazard ratio of 0.85 (95% CI, reported 6-month results of the Pa- 0.71-1.03), demonstrating that women tient-Centered Transitional Care Ser- have more of a treatment response vices in Heart Failure (PACT-HF) trial to this health care service,” she said. of 2,494 HF patients at 10 hospitals In men, rates for the first primary in Ontario during February 2015 to composite outcome were 66.3% and March 2016. They 64.1% in the intervention and usual- were randomized care groups, whereas in women to the care-tran- those rates were 59.9% and 64.8% (P sition program or = .04 for sex interaction). usual care. The In the second composite endpoint, findings, she said all-cause readmission or ED visit, at the American “again, men had an attenuated re- Heart Association sponse” with a HR of 1.03, whereas scientific sessions, women had a HR of 0.83. Results Dr. Van Spall “highlight the were similar to those for the first gap between ef- primary composite outcome: 63.4% ficacy that’s often demonstrated in and 61.7% for intervention and usual mechanistic clinical trials and effec- care in men and 57.7% and 63% in tiveness when we aim to implement women (P = .03 for sex interaction). these results in real-world settings.” In putting the findings into con- Three-month PACT-HF results were text, Dr. Van Spall said tailoring ser- reported previously (JAMA. 2019 Feb vices to risk in HF patients may be 26;321:753-61). fraught with pitfalls. “We delivered The transitional-care model con- intensive services to those patients sisted of a comprehensive needs at high risk of readmission or death, assessment by a nurse who also but it is quite possible they are the provided self-care education, a pa- least likely to derive benefit by vir- tient-centered discharge summary, tue of their advanced heart failure,” and follow-up with a family physician she said. “It may be that more ben- within 7 days of discharge, which Dr. efit would have been derived had Van Spall noted “is not current prac- we chosen low- or moderate-risk pa- tice in our health care system.” tients to receive the intervention.” Patients deemed high risk for She also said the sex-specific readmission or death also received outcomes must be interpreted with nurse home visits and scheduled vis- caution. “But they do give us pause its to a multidisciplinary heart func- to consider that services could be tion clinic in 2-4 weeks of discharge titrated more effectively if delivered and continuing as long as clinically to patients who are more likely to de- suitable, said Dr. Van Spall, a prin- rive benefit,” Dr. Van Spall said. The cipal investigator at the Population finding that women derived more Health Research Institute, Hamilton, of a benefit is in line with other pro- Ont., and assistant professor in car- spective and observational studies diology at McMaster University in that have found that women have a Hamilton. higher sense of self-care, self-effica- The trial found no difference be- cy, and confidence in managing their tween the intervention and usual- own health care needs than men. care groups in the two composite Dr. Van Spall has no financial rela- endpoints at 6 months, Dr. Van Spall tionships to disclose. the-hospitalist.org | 27 | February 2020

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