January 2019 THE OPIOID EPIDEMIC KEY CLINICAL QUESTION IN THE LITERATURE Volume 23 No. 1 U.S. Surgeon General When can anticoagulation Physician burnout may p3 weighs in. p12 resume in stroke patients? p16 jeopardize care.

Dr. Andrew White, University of Washington Medical The state Center, Seattle of hospital medicine in 2018 Productivity, pay, and roles remain center stage

By Larry Beresford

n a national health care environ- ment undergoing unprecedented transformation, the specialty of hospital medicine appears to Ibe an island of relative stability, a conclusion that is supported by the principal findings from SHM’s 2018 State of Hospital Medicine (SoHM) report. The report of hospitalist group practice characteristics, as well as other key data defining the field’s current status, that the Society of Hospital Medicine puts out every 2 years reveals that overall salaries for hospitalist physicians are up by 3.8% since 2016. Although produc- tivity, as measured by work relative value units (RVUs), remained largely flat over the same period, financial support per full-time equivalent (FTE) physician position to hospital- ist groups from their hospitals and health systems is up significantly. The median financial support Continued on page 8

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Hospitalist 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 PEDIATRIC EDITOR movers and shakers Laurence Wellikson, MD, MHM, CEO Weijen Chang, MD, FACP, SFHM [email protected] Vice President of Marketing & Communications By Matt Pesyna Dr. Fitterman has served as presi- COORDINATING EDITORS Lisa Zoks dent of SHM’s Long Island chapter. Dennis Chang, MD [email protected] THE FUTURE HOSPITALIST he Michigan chapter of the Previously, Dr. Fitterman was Marketing Communications Manager Society of Hospital Medicine chief resident at the State Universi- Jonathan Pell, MD Brett Radler KEY CLINICAL GUIDELINES [email protected] has named Peter Watson, ty of New York at Stony Brook, and Marketing Communications Specialist CONTRIBUTING WRITERS MD, SFHM, as state Hospi- he remains an associate professor at Felicia Steele Nasim Afsar, MD, MBA, SFHM [email protected] Ttalist of the Year. Dr. Watson is the Hofstra University, Hempstead, N.Y. Imuetinyan Asuen, MD vice president of care management Larry Beresford SHM BOARD OF DIRECTORS Ted Bosworth President and outcomes for Health Alliance Allen Kachalia, Nasim Afsar, MD, SFHM Andrew D. Bowser Plan (HAP) in Detroit. The Michigan MD, was named President-Elect Alissa Darden, MD chapter cited Dr. Watson’s leadership director of the Christopher Frost, MD, SFHM Erin Gabriel, MD Treasurer in hospital medicine and “generosity Armstrong Insti- Demetra Gibson, MD, MPH Danielle Scheurer, MD, MSRC, SFHM of spirit” as reasons for his selection. tute for Patient Horatio (Teddy) Holzer, MD Secretary Tracy Cardin, ACNP-BC, SFHM Aveena Kochar, MD Dr. Watson oversees nurses, social Safety and Qual- Immediate Past President Anne Linker, MD Ron Greeno, MD, FCCP, MHM workers, and support staff while ity and senior Farrin A. Manian, MD, MPH Steven B. Deitelzweig, MD, MMM, FACC, also serving as HAP Midwest Health vice president of Matt Pesyna FACP, SFHM Plan’s medical director. He’s a found- Dr. Kachalia patient safety and Daniel Restrepo, MD Howard R. Epstein, MD, SFHM Saranya Sasidharan, MD Kris Rehm, MD, SFHM ing member of the Michigan SHM quality for Johns Mitchel L. Zoler Bradley Sharpe, MD, FACP, SFHM chapter, which he formerly repre- Hopkins Medicine in Baltimore. Dr. FRONTLINE MEDICAL Jerome C. Siy, MD, SFHM Rachel Thompson, MD, MPH, SFHM sented as president. Kachalia is a general internist who COMMUNICATIONS EDITORIAL STAFF Patrick Torcson, MD, MMM, SFHM Dr. Watson spent 11 years oversee- has been an active academic hospi- Editor in Chief Mary Jo M. Dales FRONTLINE MEDICAL ing the Henry Ford Medical Group’s talist at Brigham and Women’s Hos- Executive Editors Denise Fulton, Kathy Scarbeck COMMUNICATIONS ADVERTISING STAFF hospitalist program prior to joining pital in Boston. Editor Richard Pizzi VP/Group Publisher; Director, FMC Society Partners HAP, and still works as an attending Dr. Kachalia will oversee patient Creative Director Louise A. Koenig Mark Branca hospitalist for Henry Ford. safety and quality across all of Hop- Director, Production/Manufacturing Rebecca Slebodnik Directors, Business Development kins Medicine. He also will guide Valerie Bednarz, 973-206-8954 Hyung (Harry) academic efforts for the Armstrong EDITORIAL ADVISORY BOARD cell 973-907-0230 [email protected] Geeta Arora, MD; Michael J. Beck, MD; Cho, MD, was Institute, formed recently thanks to Artie Krivopal, 973-206-8218 Harry Cho, MD; Marina S. Farah, MD, cell 973-202-5402 [email protected] named the in- a $10 million gift. MHA; Stella Fitzgibbons, MD, FACP, ClassiŽed Sales Representative augural chief In addition to his hospitalist work, FHM; Benjamin Frizner, MD, FHM; Heather Gonroski, 973-290-8259 value officer for Dr. Kachalia comes to Hopkins after Nicolas Houghton, DNP, RN, ACNP-BC; [email protected] James Kim, MD; Melody Msiska, MD; Linda Wilson, 973-290-8243 NYC Health + serving as chief quality officer and Venkataraman Palabindala, MD, SFHM; [email protected] Hospitals, which vice president of quality and safety Raj Sehgal, MD, FHM; Rehaan ShafŸe, Senior Director of ClassiŽed Sales includes 11 hospi- at Brigham Health. MD; Kranthi Sitammagari, MD; Tim LaPella, 484-921-5001 tals in New York Amith Skandhan, MD, FHM; cell 610-506-3474 [email protected] Dr. Cho Lonika Sood, MD, FACP, FHM; and is the largest Riane Dodge, PA, has been elevated Advertising OfŽces 7 Century Drive, Amanda T. Trask, FACHE, MBA, MHA, Suite 302, Parsippany, NJ 07054-4609 public health system in the United to director of clinical education in SFHM; Amit Vashist, MD, FACP; 973-206-3434, fax 973-206-9378 States. He will oversee systemwide physician assistant studies at Clark- Jill Waldman, MD, SFHM initiatives in value improvement son University, Potsdam, N.Y. The THE HOSPITALIST is the official newspaper of the Society THE HOSPITALIST (ISSN 1553-085X) is published monthly and the reduction of unnecessary veteran physician assistant previ- of Hospital Medicine, reporting on issues and trends in for the Society of Hospital Medicine by Frontline Medical testing and treatment. ously worked as a hospitalist in the hospital medicine. THE HOSPITALIST reaches more than Communications Inc., 7 Century Drive, Suite 302, Par- 35,000 hospitalists, physician assistants, nurse practitioners, sippany, NJ 07054-4609. Print subscriptions are free for Prior to this appointment, Dr. Cho Claxton Hepburn Medical Center in medical residents, and health care administrators interested Society of Hospital Medicine members. Annual paid sub- served as an academic hospitalist at Ogdensburg, N.Y. There, she cared in the practice and business of hospital medicine. Content scriptions are available to all others for the following rates: Mount Sinai Hospital for 7 years, lead- for patients in acute rehab, mental for THE HOSPITALIST is provided by Frontline Medical Communications. Content for the Society Pages is provided Individual: Domestic – $184 (One Year), $343 (Two Years), ing high-value care initiatives. Cur- health, and on regular medical floors. by the Society of Hospital Medicine. $495 (Three Years) Canada/Mexico – $271 (One Year), rently, he is a senior fellow with the Ms. Dodge also has a background $489 (Two Years), $753 (Three Years) Other Nations- Copyright 2019 Society of Hospital Medicine. All rights Surface – $335 (One Year), $646 (Two Years), $946 Lown Institute in Brookline, Mass., in urgent care and family medicine, reserved. No part of this publication may be reproduced, (Three Years) Other Nations - Air – $431 (One Year), and director of quality improvement and has experience as an emergency stored, or transmitted in any form or by any means $835 (Two Years), $1,264 (Three Years) implementation for the High Value department technician. and without the prior permission in writing from the Institution: United States – $382; copyright holder. The ideas and opinions expressed in Canada/Mexico – $463 All Other Nations – $537 Practice Academic Alliance. THE HOSPITALIST do not necessarily reflect those of the Student/Resident: $51 Society or the Publisher. The Society of Hospital Medicine The Journal of Hospital Medicine, Current – $35 (US), $47 (Canada/Mexico), and Frontline Medical Communications will not assume Single Issue: Nick Fitterman, the official peer-reviewed journal of $59 (All Other Nations) Back Issue – $47 (US), $59 responsibility for damages, loss, or claims of any kind (Canada/Mexico), $71 (All Other Nations) MD, SFHM, has SHM, has announced the appoint- arising from or related to the information contained in this been promoted to ment of Samir S. Shah, MD, MSCE, publication, including any claims related to the products, POSTMASTER: Send changes of address (with old mailing executive director SFHM to editor-in-chief, effective drugs, or services mentioned herein. label) to THE HOSPITALIST, Subscription Services, P.O. Box 3000, Denville, NJ 07834-3000. at Huntington January 1, 2019. Dr. Shah is a profes- Letters to the Editor: [email protected] To subscribe, change your address, purchase The Society of Hospital Medicine’s headquarters is located RECIPIENT: (N.Y.) Hospital. sor of pediatrics at the University of a single issue, file a missing issue claim, or have any at 1500 Spring Garden, Suite 501, Philadelphia, PA 19130. Dr. Fitterman has Cincinnati College of Medicine. questions or changes related to your subscription, call been a long-time SHM also noted the appointment Editorial Offices: 2275 Research Blvd, Suite 400, Rockville, Subscription Services at 1-833-836-2705 or e-mail [email protected]. Dr. Fitterman physician and of Jordan Messler, MD, as Physician MD 20850, 240-221-2400, fax 240-221-2548 administrator Blog Editor for The Hospital Leader, BPA Worldwide is a global industry at Huntington, serving previously SHM’s official blog. Dr. Messler is a resource for verified audience data and The Hospitalist is a member. as vice chair of medicine as well as hospitalist at Morton Plant Hospi- To learn more about SHM’s relationship with industry partners, visit www.hospitalmedicine.com/industry. head of hospitalists. talist group in Clearwater, Fla. January 2019 | 2 | The Hospitalist ANALYSIS

Q&A Defeating the opioid epidemic The U.S. Surgeon General weighs in.

ice Adm. Jerome M. Adams, MD, MPH, is medication-assisted treatment of some form. But the 20th Surgeon General of the United we also know it’s not nearly available enough and States, a post created in 1871. that there are barriers on the federal and state Dr. Adams holds degrees in biochem- levels. istryV and psychology from the University of We need you to continue to talk to your con- Maryland, Baltimore County; a master’s degree gressional representatives and let them know in public health from the University of Califor- which barriers you perceive because the data nia, Berkeley; and a medical degree from Indiana waiver comes directly from Congress. University, Indianapolis. He is a board-certified Still, any ER can prescribe up to 3 days of MAT anesthesiologist and associate clinical professor to someone. I’d much rather have our ER doctors of anesthesia at Indiana University. putting patients on MAT and then connecting At the 2018 Executive Advisory Board meet- them to treatment than sending them back out ing of the Doctors Company, Richard E. Ander- into the arms of a drug dealer after they put son, MD, FACP, chairman and chief executive them into acute withdrawal with naloxone. officer of the Doctors Company, spoke with Dr. We also have too many pregnant women who Adams about the opioid epidemic’s enormous want help but can’t find any treatment because impact on communities and health services in no one out there will take care of pregnant the United States. moms. We need folks to step up to the plate and get that data waiver in our ob.gyn. and primary Dr. Anderson: Dr. Adams, care sectors. you’ve been busy since taking Ultimately, we need hospitals and health care over as Surgeon General of the leaders to create an environment that makes pro- United States. What are some viders feel comfortable providing that service by of the key challenges that giving them the training and the support to be you’re facing in this office? Dr. Jerome M. Adams able to do it. Dr. Adams: You know, there We also need to make sure we’re coprescribing are many challenges facing our Dr. Anderson: Regarding the opioid epidemic, naloxone for those who are at risk for opioid Dr. Anderson country, but it boils down to a what would you like to see us do as a nation to overdose. lack of wellness. We know that respond to the epidemic? only 10% of health is due to health care, 20% of Dr. Adams: Recently, I was at a hospital in Alaska Dr. Anderson: Just so we are clear, are you in fa- health is genetics, and the rest is a combination where they have implemented a neonatal absti- vor of regular prescribing of naloxone, along with of behavior and environment. nence syndrome protocol and program that is prescriptions for opioids? Is that correct? My motto is “better health through better being looked at around the country – and others Dr. Adams: I issued the first Surgeon General’s partnerships” because I firmly believe that if we are attempting to replicate it. advisory in more than 10 years earlier this year break out of our silos and reach across the tradi- We know that if you keep mom and baby to- to help folks understand that over half of our tional barriers that have been put up by funding, gether, baby does better, mom does better, hos- opioid overdoses occur in a home setting. We all reimbursement, and infrastructure, then we can pital stays are shorter, costs go down, and you’re know that an anoxic brain injury occurs in 4-5 ultimately achieve wellness in our communities. keeping that family unit intact. This prevents fu- minutes. We also know that most ambulances You asked what I’ve been focused on as Surgeon ture problems for both the baby and the mother. and first responders aren’t going to show up in General. Well, I’m focused on three main areas. That’s just one small example. 4-5 minutes. No. 1 is the opioid epidemic. It is a scourge I’m also very happy to see that the prescrib- If we want to make a dent in this overdose epi- across our country. A person dies every 12½ min- ing of opioids is going down 20%-25% across the demic, we need everyone to consider themselves utes from an opioid overdose, and that’s far too country. And there are even larger decreases in a first responder. We need to look at it the same many. Especially when we know that many of the military and veteran communities. That’s as we look at CPR; we need everyone carrying those deaths can be prevented. really a testament to doctors and the medical naloxone. That was one of the big pushes from Another area I’m focused on is demonstrating profession finally waking up. And I say this as a my Surgeon General’s advisory. the link between community health and econom- physician myself, as an anesthesiologist, as some- How can providers help? Well, they can co- ic prosperity. We want folks to invest in health one who is involved in acute and chronic pain prescribe naloxone to folks on high morphine because we know that not only will it achieve management. milligram equivalents (MME) who are at risk. If better health for individuals and communities Four out of five people with substance use grandma has naloxone at home and her grandson but it will create a more prosperous nation, also. disorder say they started with a prescription opi- overdoses in the garage, then at least it’s in the And finally, I’m raising awareness about the oid. Many physicians will say, “Those aren’t my same house. Naloxone is not the treatment for links between our nation’s health and our safety patients,” but unfortunately when we look at the the opioid epidemic. But we can’t get someone and security – particularly our national security. PDMP [prescription drug–monitoring program] who is dead into treatment. Unfortunately, 7 out of 10 young people between data across the country, we do a poor job of pre- I have no illusions that simply making nalox- the ages of 18 and 24 years in our country are in- dicting who is and who isn’t going to divert. It one available is going to turn the tide, but it cer- eligible for military service. That’s because they may not be your patient, but it could be their son tainly is an important part of it. can’t pass the physical, can’t meet the educational or the babysitter who is diverting those overpre- requirements, or they have a criminal record. scribed opioids. This column was provided by the Doctors Compa- So, our nation’s poor health is not just a matter One thing that I really think we need to lean ny, the exclusively endorsed medical malpractice of diabetes or heart disease 20 or 30 years down into as health care practitioners is providing med- carrier for the Society of Hospital Medicine. Nei- the road. We are literally a less-safe country right ication-assisted treatment, or MAT. We know that ther SHM nor Frontline Medical Communications now because we’re an unhealthy country. the gold standard for treatment and recovery is was involved in its production. the-hospitalist.org | 3 | January 2019 SoHM 2018 Continued from page 1

per physician FTE was $176,657 in That said, hospitalists and group the most authoritative source of Dr. Chadha also uses the data to 2018, 12% higher than in 2016, noted leaders can’t be complacent and information regarding hospitalist help answer compensation, schedul- Leslie Flores, MHA, SFHM, of Nel- must collaborate effectively with practice, he added. “We worked ing, and support questions from his son Flores Hospital Medicine Con- hospitals to provide highly valuable hard this year to balance the partic- group’s members. sultants, and a member of SHM’s services.” Turnover of hospitalist ipants, with more of our respons- Thomas McIlraith, MD, immedi- Practice Analysis positions was up es than in the past coming from ate past chairman of the hospital Committee, which slightly, he noted, multi-hospital groups, whether 4 to medicine department at Mercy oversees the bi- at 7.4% in 2018, 5 sites, or 20 to 30.” Medical Group, Sacramento, Calif., ennial survey. from 6.9% in 2016, Surveys were conducted online said the report’s value is that it Compensation and reversing a trend in January and February of 2018 allows comparisons of salaries in productivity data of previous years. in response to invitations mailed different settings, and to see, for ex- were collected by But will these and emailed to targeted hospital ample, how night staffing is struc- 2018 SoHM Report SoHM 2018 the Medical Group trends continue medicine group leaders. A total of tured. “A lot of leaders I spoke to at Management at a time when 569 groups completed the survey, SHM’s 2018 Leadership Academy in Association and li- Ms. Flores Dr. Chadha hospitals face con- representing 8,889 hospitalist FTEs, Vancouver were saying they didn’t censed by SHM for tinued pressure to approximately 16% of the total hos- feel up to parity with the national inclusion in its report. cut costs, as the hospital medicine pitalist workforce. Responses were standards. You can use the report These findings – particularly the subsidy may represent one of their presented in several categories, in- to look at the state of hospital med- flat productivity – raise questions largest cost centers? Because the cluding by size of program, region, icine nationally and make compari- about long-term sustainability, Ms. size of hospitalist groups continues and employment model. Groups sons,” he said. Flores said. “What is going on? Do to grow, hospitals’ total subsidy for that care for adults only represented hospital administrators still rec- hospital medicine is going up faster 87.9% of the surveys, while groups Calls for more productivity ognize the value hospitalists bring than the percentage increase in sup- that care for children only were 6.7% Roberta Himebaugh, MBA, SFHM, to the operations and the quality port per FTE. and groups that care for both adults senior vice president of acute care of their hospitals? Or is paying the subsidy just a cost of doing business Understanding how hospitalists Figure 2. Un lled hospitalist positions – a necessity for most hospitals in a use the report Staf ng positions that setting where demand for hospital- Dr. White called the 2018 SoHM re- Hospital medicine groups with un lled positions ist positions remains high?” port the “most representative and remained un lled during the Andrew White, MD, FACP, SFHM, balanced sample to date” of hospital- year in groups Adult chair of SHM’s Practice Analysis ist group practices, with some of the serving only 66.4% Committee and director of the hos- highest quality data, thanks to more adults pital medicine service at the Univer- robust participation in the survey only. 12% sity of Washington Medical Center, by pediatric groups and improved Children Seattle, said basic market forces distribution among hospitalist man- only 48.4% dictate that it is “pretty much incon- agement companies and academic ceivable” to run a modern hospital of programs. any size without hospitalists. “Not that past reports had major Adults and 52.6% 44% of those adult-only “Clearly, demand outstrips sup- flaws, but this version is more au- children groups used locums staff to EWS

ply, which drives up salaries and thoritative, reflecting an intentional N support, whether CEOs feel that effort by our Practice Analysis Com- ll positions. EDGE Source: 2018 State of Hospital Medicine Report the hospitalist group is earning mittee to bring in more participants MD that support or not,” Dr. White said. from key groups,” he said. “The unfilled hospitalist positions The biennial report has been and children were 5.4%. services for the national hospitalist we identified speak to ongoing pro- around long enough to achieve “This survey doesn’t tell us what management company TeamHealth, jected greater demand than supply. brand recognition in the field as should be best practice in hospital and co-chair of the SHM Practice medicine,” Dr. White said, only what Administrators Special Interest Figure 1. Compensation and productivity is actual current practice. He uses it Group, said her company’s clients NONACADEMIC ADULT MEDICINE HOSPITALISTS in his own health system not only to have traditionally asked for greater contextualize and justify his group’s productivity from their hospitalist $300,000 5,000 performance metrics for hospital contracts as a way to decrease over- administrators – relative to national all costs. Some markets are starting and categorical averages – but also to see a change in that approach, to see if the direction his group is she noted. $250,000 4,000 following is consistent with what’s “Recently there’s been an in- going on in the larger field. creased focus on paying hospitalists “These data offer a very powerful to focus on quality rather than just resource regarding the trends in hos- productivity. Some of our clients $200,000 3,000 pital medicine,” said Romil Chadha, are willing to pay for that, and we MD, MPH, FACP, SFHM, associate are trying to assign value to this

EWS division chief for operations in the nonbillable time or adjust our pro- N division of hospital medicine at the ductivity standards appropriately. EDGE University of Kentucky and UK I think hospitals definitely under- 0 0 MD 2016 2018 2016 2018 Healthcare, Lexington. “It is my re- stand the value of nonbillable ser- Median total compensation Median productivity (RVUs) pository of data to go before my ad- vices from hospitalists, but still will ministrators for decisions that need push us on the productivity targets,” Source: 2018 State of Hospital Medicine Report to be made or to pilot new programs.” Ms. Himebaugh said. January 2019 | 8 | The Hospitalist “I don’t believe hospital medicine licensed for inclusion in the SoHM How is hospitalist practice 2016 to 75.7% in 2018. For adult-only can be sustainable long term on flat report. evolving? groups, 76.8% had NPs/PAs, with productivity or flat RVUs,” she add- “There is no source of absolute In addition to payment and pro- higher rates in hospitals and health ed. “Yet the costs of burnout associ- truth that hospitalists can point ductivity data, the SoHM report systems and lower rates in the West ated with pushing to,” Dr. Williams said. “I will present provides a current picture of the region. But a lot of groups are using 2018 SoHM Report higher productiv- my data and my administrators will evolving state of hospitalist group these practitioners for nonproduc- ity are not sus- reply: ‘We have our own data.’ Our practices. A key thread is how the tive work, and some are failing to tainable, either.” institution has consistently ranked work hospitalists are doing, and the generate any billing income, Dr. So what are the first or second nationwide for the way they do it, is changing, with Brown said. answers? She said sickest patients. We take more Med- new information about comanage- “The rate at which NPs/PAs per- many inefficien- icaid and dually eligible patients, ment roles, dedicated admitters, formed billable services was high- cies are involved who have a lot of social issues. They night coverage, geographic round- er in physician-owned practices, in responding to take a lot of time to manage medi- ing, and the like. resulting in a lower cost per RVU, inquiries on the Dr. McIlraith cally and the RVUs don’t reflect that. Making greater use of nurse suggesting that many practices may floor that could And yet I’m still judged by my RVUs practitioners and physician assis- be underutilizing their NPs/PAs or have been ad- generated per hospitalist. Hospital tants (NPs/PAs), may be one way to not sharing the work.” Not every NP dressed another administrators understandably change the flat productivity trends, or PA wants to or is able to care for way, or waiting for want to get the most productivity, Dr. Brown said. With a cost per RVU very complex patients, Dr. Brown the turnaround of and they are looking for their own that’s roughly half that of a doctor’s, said, “but you want a system where diagnostic tests. data for average productivity num- NPs/PAs could contribute to the the NP and PA can work at the high- “Maybe we don’t bers.” est level permitted need physicians to Ryan Brown, MD, specialty med- Figure 4. How are NP/PA services billed? by state law.” be in the hospital ical director for hospital medicine The predominant 24/7 if we have ac- Ms. Himebaugh with Atrium Health in Charlotte, scheduling model cess to telehealth, N.C., said that hospital medicine’s 22.4% NP/PA work billed independently under NP/PA’s of hospital medi- or a partnership flat productivity trends would be provider number when allowed by the payer cine, 7 days on duty with the emergen- difficult to sustain in the business followed by 7 days cy department, or world. But there aren’t easy or ob- off, has diminished 29.1% Billed as shared services under collaborating/ greater use of ad- vious ways to increase hospitalists’ supervising physician’s provider number somewhat in recent vanced care prac- productivity. The SoHM report also years. There appears tice providers,” Ms. shows that, as productivity increas- to be some fluctua- Himebaugh said. es, total compensation increases but tion and a gradual “Our hospitals are at a lower rate, resulting in a gradual move away from 38.3% Combined model examining those Dr. Williams decrease in compensation per RVU. 7 on/7 off toward

options, and we Pressures to increase productivity EWS some kind of vari- have to look at how we can become can be a double-edged sword, Dr. N able approach, since more efficient and less costly. At Williams added. Demanding that 10.1% NP/PAs didn’t generally provide billable services EDGE the former may TeamHealth, we are trying to staff doctors make more billable visits MD not be physically for value – looking at patient flow faster to generate more RVUs can be Source: 2018 State of Hospital Medicine Report sustainable for the patterns and adjusting our sched- a recipe for burnout and turnover, doctor over the long ules accordingly. Is there a bolus of with huge costs associated with re- haul, Dr. Brown said. admissions tied to emergency de- cruiting replacements. bottom line. But he sees surprisingly Some groups are experimenting partment shift changes, or to certain “If there was recent turnover of large variation in how hospitalist with a combined approach. days of the week? How can we move hospitalists at the hospital, with the groups are using them. Typically, “I think balancing workload with from the 12-hour shift that begins at need to find replacements, there they are deployed at a ratio of four manpower has always been a chal- 7 a.m. and ends at 7 p.m., and instead may be institutional memory about doctors to one NP/PA, but that ratio lenge for our field. Maybe we should provide coverage for when the pa- that,” he said. “But where are hospi- could be two to one or even one to be working shorter shifts or fewer tients are there?” tals spending their money? Bottom one, he said. days and making sure our hospital- Mark Williams, MD, MHM, chief of line, we still need to learn to cut our Use of NPs/PAs by academic hos- ists aren’t ever sitting around idle,” the division of hospital medicine at costs.” pitalist groups is up, from 52.1% in he said. “And could we come in on the University of Kentucky, Lexing- nonclinical days to do administra- ton, said he appreciates the volume Figure 3. Employment model for groups participating in the survey tive tasks? I think the solution is of data in the report but wishes out there, but we haven’t created for even more survey participants, the algorithms to define that yet. which could make the breakouts for Hospitals, health If you could somehow use the data subgroups such as academic hospi- Other systems, or integrated for volume, number of beds, nurse talists more robust. Other current 1.7% delivery systems staffing, etc., by year and seasonally, sources of hospitalist salary data you might be able to reliably pre- Private multispecialty 52.1% include the Association of American or primary care dict census. This is about applying Medical Colleges (AAMC), which medical groups data hospitals already have in their produces compensation reports to 7.5% electronic health records, but utiliz- help medical schools and teaching ing the data in ways that are more hospitals with benchmarking, and University medical helpful.” the Faculty Practice Solution Cen- school or faculty Multistate hospitalist Dr. McIlraith added that a big ter developed jointly by AAMC and practice plans management driver of the future of hospital med- 13.8% Academic hospitalist groups companies Vizient to provide faculty practice 24.9% EWS icine will be the evolution of the plans with analytic tools. The Medi- represented 21.1% of participants, N EHR and the digitalization of health cal Group Management Association up from 14.8% in 2016. EDGE care, as hospitals learn how to lever- (MGMA) is another valuable source MD age more of what’s in their EHRs. of information, some of which was Source: 2018 State of Hospital Medicine Report Continued on following page the-hospitalist.org | 9 | January 2019 Continued from previous page shifts in exchange for 2 weeks of to be an academic hospitalist as our volume-to-value shift in health care “The impact will grow for hospital- backup. We have times with 25% teaching roles have shrunk.” – how are these new models affect- ists through the creation and matu- usage of backup number 1, and 10% Dr. Huang recently took on a new ing hospitalists? ration of big data systems – and the usage of backup number 2,” he not- role as physician adviser for his Observers say penetration of learning that can ed. “But the goal is hospital in such areas as utilization these new models varies widely by be extracted from for our hospitalists review, patient flow, and length locality but they haven’t had much what’s contained to have assuranc- of stay. “I’m spearheading a work direct impact on hospitalists’ prac- in the electronic es that there is a group to address health record.” backup system and quality issues – all of Figure 7. Outside the hospital Another import- that it works.” which involve collab- ant question for The presence of oration with other Care provided outside of the hospital by hospitalists hospitalist groups nocturnists in hos- professionals. We is their model of pitals continues also developed an ad- Care of patients on backup schedul- Dr. Brown Dr. Huang to rise, with 76.1% mitting role here for other specialized ing, to make sure of adults-only a hospitalist whose 26.0% 2018 SoHM Report SoHM 2018 units or facilities there is a replacement available if a groups having nocturnists, 27.6% sole role for the day scheduled doctor calls in sick or if of children-only groups, and 68.2% is to admit patients.” Care of patients demand is unexpectedly high. of adults and children groups. Nationally up to 51.2% in post–acute care 24.8% “In today’s world, this is how we Geographic or unit-based hospital of hospitalist groups units/facilities have traditionally managed unpre- assignments have grown to 36.4% of utilize a dedicated dictability,” Dr. Brown said. “You adult-only groups. daytime admitter. Outpatient work don’t know when you will need it, The report found 17.3% but if you need it, you want it im- What are hospitalists’ other that hospital services mediately. So how do you pay for new roles? for which hospitalists it – only when the doctor comes in, “We have a large group of 50 doctors, are more likely to be or also an amount just for being on with about 40 FTEs, and we are attendings than con- KaraGrubis/Thinkstock call?” Some groups pay for both, he evolving from the traditional gener- sultants include GI/ said, others for neither. alist role toward more subspecialty liver, 78.4%; palliative care, 77.3%; neurology/ Figure 5. Predominant scheduling patterns for adult-only groups stroke, 73.6%; oncolo- gy, 67.8%; cardiology, EWS

56.9%; and critical N care, 50.7%. Conditions 7 on, 7 off EDGE Source: 2018 State of Hospital Medicine Report where hospitalists are MD Other xed, rotating more likely to con- block schedules sult rather than admit and attend tices – at least not yet. However, as include neurosurgery, orthopedics, hospitals and health systems find M-F with rotation general surgery, cardiovascular themselves needing to learn new of weekend surgery, and other surgical subspe- ways to invest their resources dif- cialties. ferently in response to these trends,

Variable EWS Other hospital services routinely what matters to the hospital should N provided by adult-only hospitalists be of great importance to the hospi- 0 10% 20% 30% 40% 50% 60% EDGE include care of patients in an ICU talist group. MD setting (62.7%); primary responsibili- “I haven’t seen a lot of dramatic Source: 2018 State of Hospital Medicine Report ty for observa tion units (54.6%); pri- changes in how hospitalists engage mary clinical responsibility for rapid with value-based purchasing,” Dr. “We are a group of 70 hospitalists, comanagement,” said Bryan Huang, response teams (48.8%); primary re- White said. “If we know that some- and if someone is sick you can’t MD, physician adviser and associate sponsibility for code blue or cardiac one is part of an ACO, the instinctu- just shut down the service,” said Dr. clinical professor in the division of arrest teams (43.8%); nighttime ad- al – and right – response is to treat Chadha. “We are one of the few to hospital medicine at the University missions or tuck-in services (33.9%); them like any other patient. But we use incentives for both, which could of California–San Diego. “Our hos- and medical procedures (31.5%). For still need to be committed to not include a 1-week decrease in clinical pitalists are asking what it means pediatric hospital medicine groups, waste resources.” care of healthy newborns and med- Hospitalists are the best people to Figure 6. Predominant night coverage models for adult groups ical procedures were among the understand the intricacies of how most common services provided, the health care system works under while for hospitalists serving adults value-based approaches, Dr. Huang On-call coverage via telephone and children, rapid response teams, said. “That’s why so many hospital- 6.3% by off-site hospitalist ICUs, and specialty units were most ists have taken leadership positions common. in their hospitals. I think all of this Scheduled on-site Coverage via telemedicine 1.3% translates to the practical, day-to- presence of physician hospitalist New models of payment for day work of hospitalists, reflected 80% health care in our focus on readmissions and 11.6% Combination of on-site and off- As the larger health care system length of stay.” site coverage, or another model is being transformed by new pay- Dr. Williams said the health ment models and benefit struc- care system still hasn’t turned EWS

N tures, including accountable care the corner from fee-for-service to organizations (ACOs), value-based value-based purchasing. “It still 1.0% No hospitalist physician EDGE

responsibility for coverage MD purchasing, bundled payments, and represents a tiny fraction of the in- other forms of population-based come of hospitalists. Hospitals still Source: 2018 State of Hospital Medicine Report coverage – which is described as a Continued on following page January 2019 | 10 | The Hospitalist Continued from previous page have to focus on the bottom line, SHM announces National as fee-for-service reimbursement for hospitalized patients contin- ues to get squeezed, and ACOs ar- Hospitalist Day en’t exactly paying premium rates either. Ask almost any hospital Inaugural day of recognition to honor hospital medicine care team CEO what drives their bottom line today and the answer is volume – By Brett Radler tors, C-suite executives, and academic hospitalists. along with optimizing productivi- Highlights of SHM’s campaign include the following: ty. Pretty much every place I look, he Society of Hospital Medicine is proud to an- • Downloadable customizable posters and assets for the future does not look terribly nounce the inaugural National Hospitalist Day, hospitals and individuals’ offices to celebrate their rosy for hospitals.” which is to be held on Thursday, March 7, 2019. hospital medicine team, available on SHM’s website, Ms. Himebaugh said she is bull- Occurring the first Thursday in March annual- hospitalmedicine.org. ish on hospital medicine, in the Tly, National Hospitalist Day will serve to celebrate the • A series of spotlights of hospitalists at all stages of sense that it’s unlikely to go away fastest-growing specialty in modern medicine and hos- their careers in The Hospitalist, SHM’s monthly news- anytime soon. “Hospitalists are pitalists’ enduring contributions to the evolving health magazine. needed and provide value. But I care landscape. • A social media campaign inviting hospitalists and don’t think we have devised the National Hospitalist Day was recently approved by their employers to share their success stories using right model yet. I’m not sure our the National Day Calendar and was one of approxi- the hashtag #HowWeHospitalist, including banner current model is sustainable. We mately 30 national days to be approved for the year out graphics, profile photo overlays, and more. need to find new models we can of an applicant pool of more than 18,000. • A social media contest to determine the most creative afford that don’t require squeezing “As the only national professional society dedicated ways of celebrating with use of the hashtag. our providers.” to the specialty of hospital medicine, it is appropriate • A Twitter chat for hospitalists to celebrate virtually that SHM spearhead a national day to recognize the with colleagues and peers from around the world. For more information about the countless contributions of hospitalists to health care, “Hospitalists innovate, lead, and push the boundaries 2018 State of Hospital Medicine from clinical, academic, and leadership perspectives of clinical care and deserve to be recognized for their Report, contact SHM’s Prac- and more,” said Larry Wellikson, MD, MHM, chief exec- transformative contributions to health care,” said Eric tice Management Department utive officer of SHM. E. Howell, MD, MHM, chief operating officer of SHM. at survey@hospitalmedicine. In addition to celebrating hospitalists’ contributions For more information, visit www.hospitalmedicine. org or call 800-843-3360. See also to patient care, SHM will also be highlighting the di- org/hospitalistday. https://www.hospitalmedicine. verse career paths of hospital medicine professionals, org/practice-management/ from frontline hospitalist physicians, nurse practi- Mr. Radler is marketing communications manager at shms-state-of-hospital-medicine/. tioners, and physician assistants to practice administra- the Society of Hospital Medicine. N PAC 2 019 March 11 - March 13, 2019 National Physician Advisor Conference Grand Hyatt Atlanta • Atlanta, GA

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the-hospitalist.org | 11 | January 2019 CLINICAL

Key Clinical Question When is it safe to resume anticoagulation in my patient with hemorrhagic stroke? Balancing risk is critical to decision making

By Demetra Gibson, MD, MPH; Daniel Restrepo, MD; Saranya Sasidharan, MD; and Farrin A. Manian, MD, MPH Department of Medicine, Massachusetts General Hospital, Boston

deep ICH (i.e., involving the thal- ami, basal ganglia, cerebellum, or Case brainstem) where cerebral amyloid A 75-year-old woman angiopathy is rare and ICH is usual- with a history of hyper- ly from hypertensive vessel disease. tension, diabetes melli- However, in patients with active tus, heart failure, and thromboembolic disease, high-risk nonvalvular atrial fibril- atrial fibrillation, and mechanical

lation (CHA2DS2-VASc valves, withholding anticoagulation Dr. Gibson Dr. Restrepo score, 8) on anticoagu- could place them at high risk of lation is admitted with stroke. weakness and dysarthria. Two questions should be ad- Exam is notable for hy- dressed in the case presented: Is it pertension and right-sid- safe to restart therapeutic anticoag- ed hemiparesis. CT of the ulation; and if so, what is the opti- head shows an intrapa- mal time interval between ICH and renchymal hemorrhage in reinitiation of anticoagulation? the left putamen. Her an- ticoagulation is reversed Overview of the data Dr. Sasidharan Dr. Manian MAGES

and blood pressure well I There is limited guidance from ma-

controlled. She is dis- ETTY jor professional societies regarding Dr. Gibson, Dr. Restrepo, charged 12 days later. /G the reinitiation of anticoagulation Dr. Sasidhara, and Dr. Manian and the optimal timing of safely re- are hospitalists at Massachusetts suming anticoagulation in patients General Hospital, Boston. WANGMOOZAA

K with prior ICH. Current European Stroke Organi- Brief overview of the issue decreases the risk of stroke/throm- zation guidelines provide no specific meta-analysis of 5,300 patients Intracranial hemorrhage (ICH) is boembolism, it may also increase recommendations for anticoagu- with nonlobar ICH involving eight the second most common cause the amount of bleeding associated lation resumption after ICH.7 The retrospective studies, Murthy et al. of stroke and is associated with with the initial ICH or lead to its American Heart Association/Amer- evaluated the risk of thromboembol- high morbidity and mortality.1 It is recurrence. ican Stroke Association guideline ic events (described as a composite estimated that 10%-15% of sponta- Factors that may contribute to has a class IIA (weak) recommen- outcome of MI and stroke) and the neous ICH cases occur in patients rebleeding include uncontrolled dation to avoid anticoagulation in risk of recurrent ICH.8 They report- on therapeutic anticoagulation for hypertension, advanced age, time to spontaneous lobar ICH and a class ed that resumption of therapeutic atrial fibrillation.2 As our population resumption of anticoagulation, and IIB (very weak) recommendation to anticoagulation was associated with ages and more people develop atri- lobar location of ICH (i.e., in cerebral consider resuming anticoagulation a decrease in the rate of thromboem- al fibrillation, anticoagulation for cortex and/or underlying white mat- in nonlobar ICH on a case-by-case bolic events (6.7% vs. 17.6%; risk ratio, primary or secondary prevention ter).5,6 Traditionally, lobar ICH has basis.4 0.35; 95% confidence interval, 0.25- of embolic stroke also will likely high incidence of cerebral amyloid Two recent meta-analyses have 0.45) with no significant change in increase, placing more people at risk angiopathy and has been associated examined outcomes of resuming the rate of repeat ICH (8.7% vs. 7.8%). for ICH. Even stringently controlled with higher bleeding rates than has anticoagulation after ICH. In a A second meta-analysis conducted therapeutic international normal- by Biffi et al. of three retrospective ized ratios (INRs) between 2 and 3 Key Points trials examined anticoagulation may double the risk of ICH.3 resumption in 1,012 patients with Patients with ICH require close • Robust scientific data on when to resume anticoagulation after ICH do ICH solely in the setting of throm- monitoring and treatment, includ- not exist. boprophylaxis for nonvalvular atrial ing blood pressure control, reversal • Retrospective studies have shown that anticoagulation resumption fibrillation.9 Reinitiation of antico- of anticoagulation, reduction of after 4-8 weeks decreases the risk of thromboembolic events, decreas- agulation after ICH was associated intracranial pressure, and at times, es mortality, and improves functional status following ICH with no with decreased mortality (hazard neurosurgery.4 Although anticoagu- significant change in the risk of its recurrence. ratio, 0.27; 95% CI, 0.19-0.40; P less lation is discontinued and reversed • Prospective, randomized controlled trials are needed to explore risks/ than .0001), improved functional at the onset of ICH, no clear con- benefits of anticoagulation resumption and better define its optimal outcome (HR, 4.15; 95% CI, 2.92-5.90; sensus exists as to when it is safe to timing in relation to ICH. P less than .0001), and reduction in resume it. Although anticoagulation Continued on page 14 January 2019 | 12 | The Hospitalist Intensive Caring for a Continued Recovery

v

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8/13/2018 11:13:01 AM HOSP_13LQGG CLINICAL | Key Clinical Question

Continued from page 12 Quiz stress that a causal relationship all-cause stroke recurrence (HR 0.47; between use of anticoagulants and 95% CI, 0.36-0.64; P less than .0001). Which of the following is false regarding ICH? certain outcomes or adverse effects There was no significant difference A. Lobar ICHs are usually associated with cerebral amyloid angiopathy following ICH may be more difficult in the rate of recurrent ICH when which are prone to bleeding. to invoke in the absence of random- anticoagulation was resumed. De- B. Randomized, controlled studies have helped guide the decision as to ized controlled study designs. spite the notion that patients with when to resume anticoagulation in patients with ICH. cerebral amyloid angiopathy are at C. Current guidelines suggest deferring therapeutic anticoagulation for Application of the data to our high risk of rebleeding, this positive at least 4 weeks following ICH. patient association still held irrespective of D. Resumption of anticoagulation after 4-8 weeks does not lead to Resumption of anticoagulation in lobar vs. nonlobar location of ICH. increased risk of rebleeding in patients with prior ICH. our patient with ICH requires bal- Collectively, these studies suggest ancing the risk of hemorrhage ex- that resumption of anticoagulation The false answer is B: Current recommendations regarding resumption pansion and recurrent ICH with the may be effective in decreasing the of anticoagulation in patients with ICH are based solely on retrospective risk of thromboembolic disease. rates of thromboembolism, as well observational studies; there are no randomized, control trials to date. Our patient is at higher risk of as provide a functional and mortal- A is true: In contrast to hypertensive vessel disease associated with deep bleeding because of her advanced ity benefit without increasing the ICH, lobar hemorrhages are usually associated with cerebral amyloid age, but adequate control of her risk of rebleeding, irrespective of the angiopathy, which are more prone to bleeding. blood pressure and nonlobar loca- location of the bleed. C is true: The AHA/ASA has a class IIB recommendation to avoid antico- tion of her ICH in the basal ganglia Less is known about the optimal agulation for at least 4 weeks after ICH in patients without mechanical also may decrease her risk of recur- timing of resumption of therapeutic heart valves. rent ICH. Her high CHA2DS2-VASc anticoagulation, with data ranging D is true: Several studies have shown that resumption of anticoagulation score places her at high risk of from 72 hours to 30 weeks.10 The 4-8 weeks after ICH does not increase the risk of rebleeding. thromboembolic event and stroke, American Heart Association/Amer- making it more likely for reinitiation ican Stroke Association has a class of anticoagulation to confer a mor- IIB (very weak) recommendation to 2,619 ICH survivors explored the occurring at least 28 days after ini- tality benefit. avoid anticoagulation for at least relationship between the timing of tial ICH in patients with atrial fibril- Based on AHA guidelines,4 we 4 weeks in patients without me- reinitiation of anticoagulation and lation.11 should wait at least 4 weeks, or pos- chanical heart valves.4 The median the incidence of thrombotic events A decrease in thrombotic events sibly wait until weeks 7-8 after ICH time to resumption of therapeutic (defined as ischemic stroke or death was demonstrated if anticoagulation when the greatest benefit may be ex- anticoagulation in aforementioned because of MI or systemic arterial was started 4-16 weeks after ICH. pected based on prediction models.11 meta-analyses ranged from 10 to 44 thromboembolism) and hemorrhag- However, when anticoagulation was days.8,9 ic events (defined as recurrent ICH started more than 16 weeks after Bottom line A recent observational study of or bleeding event leading to death) ICH, no benefit was seen. Additional- It would likely be safe to resume an- ly, there was no significant difference ticoagulation 4-8 weeks after ICH in in hemorrhagic events between men our patient. and women who resumed anticoagu- lation. In patients with high venous References thromboembolism risk based on 1. An SJ et al. Epidemiology, risk factors, and CHA DS -VASc score, resumption of clinical features of intracerebral hemorrhage: An 2 2 update. J Stroke. 2017 Jan;19:3-10. anticoagulation was associated with a decreased predicted incidence of 2. Horstmann S et al. Intracerebral hemorrhage during anticoagulation with vitamin K antag- vascular death and nonfatal stroke, onists: A consecutive observational study. J with the greatest benefit observed Neurol. 2013 Aug;260:2046-51. when anticoagulation was started at 3. Rosand J et al. The effect of warfarin and 7-8 weeks after ICH. intensity of anticoagulation on outcome of intracerebral hemorrhage. Arch Intern Med. Unfortunately, published liter- 2004 Apr 26;164:880-4. ature to date on anticoagulation 4. Hemphill JC et al. Guidelines for the manage- after ICH is based entirely on retro- ment of spontaneous intracerebral hemorrhage. spective studies – not randomized, Stroke. 2015 Jul;46:2032-60. controlled studies – making it more 5. Aguillar MI et al. Update in intracerebral hemorrhage. Neurohospitalist. 2011;1:148-59. Ready for likely that anticoagulation would 6. Hill MD et al. Rate of stroke recurrence in have been resumed in healthier pa- patients with primary intracerebral hemorrhage. UHFHUWLƓFDWLRQ" tients, not those left debilitated by Stroke. 2000;31:123-7. the ICH. 7. Steiner T et al. European Stroke Organiza- Furthermore, information on the tion (ESO) guidelines for the management of location and size of the hemorrhag- spontaneous cerebral hemorrhage. Int J Stroke. 2014;9:840-55. es – which may serve as another &RPLQJ6RRQSpark Edition 2 8. Murthy SB et al. Restarting anticoagulation confounding factor – often has not therapy after intracranial hemorrhage: A system- Ace the FPHM exam with the only study tool created been reported. This is important atic review and meta-analysis. Stroke. 2017 Jun;48:1594-600. by hospitalists, for hospitalists. since patients with smaller hemor- rhages in less precarious areas also 9. Biffi A et al. Oral anticoagulation and func- tional outcome after intracerebral hemorrhage. /HDUQPRUH hospitalmedicine.org/spark may be more likely to have resump- Ann Neurol. 2017 Nov;82:755-65. tion of anticoagulation. Another 10. Witt DM. What to do after the bleed: Resum- limitation of the current literature ing anticoagulation after major bleeding. Hema- is that warfarin is the most common tology Am Soc Hematol Educ Program. 2016 anticoagulant studied, with few Dec 2;206:620-4. studies involving the increasingly 11. Pennlert J et al. Optimal timing of anticoag- ulant treatment after intracerebral hemorrhage prescribed newer direct oral anti- in patients with atrial fibrillation. Stroke. 2017 coagulants. It is also important to Feb;48:314-20. January 2019 | 14 | The Hospitalist CLINICAL Acute stroke thrombolysis worked safely despite GI bleed or malignancy

By Mitchel L. Zoler prior year for a GI malignancy and MDedge News 43 with a diagnostic code within the prior 21 days for a GI bleed. FROM THE AHA SCIENTIFIC SESSIONS Dr. Inohara and his associates de- / CHICAGO / A recent history of GI termined patients’ mortality during bleeding or malignancy may not be their stroke hospitalization, as well a valid contraindication to throm- as several measures of functional bolytic therapy in patients with an recovery at hospital discharge and acute ischemic stroke, based on a thrombolysis-related complications. review of outcomes from more than For each of these endpoints, the rate 40,000 U.S. stroke patients. among patients with a GI malignan- The analysis cy, a GI bleed, or the rate among a showed that, combined group of both patients among 40,396 U.S. showed no statistically significant patients who had differences, compared with the more an acute ischemic than 40,000 other patients without stroke during a GI complication after adjustment 2009-2015 and for several demographic and clinical received timely between-group differences. However, treatment with Dr. Inohara cautioned that residual Dr. Inohara alteplase, “we did or unmeasured confounding may not find statisti- exist that distorts these findings. cally significant increased rates of The rate of in-hospital mortality, the in-hospital mortality or bleeding” in prespecified primary endpoint for the small number of patients who the analysis, was 10% among patients received alteplase (Activase) despite with either type of GI complication a recent GI bleed or diagnosed GI and 9% in those without. The rate of malignancy, Taku Inohara, MD, said serious thrombolysis-related compli- at the American Heart Association cations was 7% in the patients with scientific sessions. The 2018 Guide- GI disease and 9% in those without. See you lines for the Early Management of In a separate analysis of the com- Patients With Acute Ischemic Stroke plete database of more than 633,000 deemed thrombolytic therapy with patients, Dr. Inohara and his asso- alteplase in these types of patients ciates found 148 patients who had on the Hill. contraindicated, based on consen- either a GI bleed or malignancy and sus expert opinion (Stroke. 2018 otherwise qualified for thrombolyt- Mar;49[3]:e66-110). ic therapy but did not receive this “Further study is needed to eval- treatment. This meant that, overall Join fellow hospitalists on uate the safety of recombinant in this large U.S. experience, 136 tissue–type plasminogen activator of 284 (48%) acute ischemic stroke Capitol Hill to meet with [alteplase] in this specific popula- patients who qualified for throm- tion,” said Dr. Inohara, a cardiologist bolysis but had a GI complication Congressional offices during and research fellow at Duke Univer- nonetheless received thrombolysis. Hospital Medicine 2019. sity, Durham, N.C. Further analysis showed that the His analysis used data collected by patients not treated with thrombol- the Get With the Guidelines–Stroke ysis had at admission an average Hill Day is March 27, 2019 program, a voluntary quality promo- National Institutes of Health Stroke shmannualconference.org/hill-day tion and improvement program that Scale score of 11, compared with an during 2009-2015 included records average score of 14 among patients for more than 633,000 U.S. stroke who received thrombolysis. patients that could be linked with This apparent selection for throm- records kept by the Centers for Medi- bolytic treatment of patients with care & Medicaid Services. From this more severe strokes “may have over- database, 40,396 patients (6%) treated estimated risk in the patients with with alteplase within 4.5 hours of GI disease,” Dr. Inohara said. ® stroke onset were identified. The Dr. Inohara reported receiving alteplase-treated patients included research funding from Boston Sci- 93 with a diagnosis code during the entific. the-hospitalist.org | 15 | January 2019 CLINICAL

In the Literature ITL: Clinician reviews of HM-centric research By Erin Gabriel, MD; Horatio (Teddy) Holzer, MD; Anne Linker, MD; Aveena Kochar, MD; and Imuetinyan Asuen, MD Division of Hospital Medicine at Mount Sinai Hospital, New York

IN THIS ISSUE gram-negative bacilli are becoming Dr. Gabriel is assistant professor of increasingly common. Carbapenems medicine and director of Preopera- 1. Physician burnout may be jeopardizing patient care are considered the treatment of tive Medicine and Medicine Consult 2. No Pip/Tazo for patients with ESBL blood stream infections choice for these infections, but they Service in the division of hospital 3. New single-dose influenza therapy effective among outpatients may in turn select for carbapenem- medicine at Mount Sinai Hospital, 4. What drives intensification of antihypertensive therapy at discharge? resistant gram-negative bacilli. New York. 5. Repeated qSOFA measurements better predict in-hospital mortality STUDY DESIGN: Open-label, nonin- from sepsis feriority, randomized clinical trial. By Horatio (Teddy) Holzer, MD 6. Daily aspirin use may not improve CV outcomes in healthy elderly SETTING: Adult inpatients from New single-dose influenza 7. Mitral valve repair improves prognosis in heart failure patients with sec- nine countries (not including the 3 therapy effective among ondary MR United States). outpatients 8. Same-day discharge after elective PCI has increased value and patient SYNOPSIS: Patients with at least satisfaction one positive blood culture for CLINICAL QUESTION: Is baloxavir 9. Adjustment for characteristics not used by Medicare reduces hospital ESBL E. coli or K. pneumoniae were marboxil, a selective inhibitor of variations in readmission rates screened. Of the initial 1,646 patients influenza cap-dependent endonucle- 10. Uncomplicated appendicitis can be treated successfully with antibiotics assessed, only 391 were enrolled (866 ase, a safe and effective treatment met exclusion criteria, 218 patients for acute uncomplicated influenza? declined, and 123 treating physicians BACKGROUND: The emergence By Erin Gabriel, MD fessionalism than were late-career declined). Patients were random- of oseltamivir-resistant influenza Physician burnout may be physicians. ized within 72 hours of the positive A(H1NI) infection in 2007 highlights 1 jeopardizing patient care Of the components of burnout, blood culture collection to either the risk of future neuraminidase-re- depersonalization was most strong- piperacillin/tazobactam 4.5 g every sistant global pandemics. Baloxavir CLINICAL QUESTION: Is physician ly associated with these negative 6 hours or meropenem 1 g every 8 represents a new class of antiviral burnout associated with more pa- outcomes. In- hours. Patients were treated from agent that may help treat such out- tient safety issues, low professional- terestingly, the 4 to 14 days, with the total duration breaks. ism, or poor patient satisfaction? increased risk of of antibiotics left up to the treating STUDY DESIGN: Phase 3 random- BACKGROUND: Burnout is com- patient safety physician. ized, double-blind, placebo-con- mon among physicians and has a incidents was The primary outcome was all- trolled trial. negative effect on their personal associated with cause mortality at 30 days after ran- SETTING: Outpatients in the United lives. It is unclear whether physician physician-report- domization. The study was stopped States and Japan. burnout is associated with poor out- ed, but not health early because of a significant mor- SYNOPSIS: The trial recruited 1,436 comes for patients. care system–re- tality difference between the two otherwise healthy patients aged 12-64 STUDY DESIGN: Meta-analysis. Dr. Gabriel ported, patient groups (12.3% in the piperacillin/ years of age (median age, 33 years) SETTING: Forty-seven published safety outcomes. tazobactam group versus 3.7% in the with a clinical diagnosis of acute un- studies from 19 countries assessing This raises concerns that the health meropenem group). complicated influenza pneumonia. inpatient and outpatient physicians care systems may not be capturing The overall mortality rate was The patients were randomly assigned and the relationship between physi- “near misses” in their metrics. lower than expected. The sickest to receive either a single dose of oral cian burnout and patient care. BOTTOM LINE: Physician burnout patients may have been excluded baloxavir, oseltamivir 75 mg twice SYNOPSIS: After a systematic re- doubles the risk of being involved because the treating physician daily for 5 days, or matching placebo view of the published literature, 47 in a patient safety incident, low needed to approve enrollment. within 48 hours of symptom onset. studies were included to pool data professionalism, and poor patient Because of the necessity for em- The primary outcome was patient from 42,473 physicians. Study sub- satisfaction. piric antibiotic therapy, there was self-assessment of symptomatology. jects included residents, early-career CITATION: Panagioti M et al. Asso- substantial crossover in antibiotics Among the 1,064 adult patients and late-career physicians, and both ciation between physician burnout between the groups, although this (age 20-64) with influenza diagnosis hospital and outpatient physicians. and patient safety, professionalism, would have biased the study to- confirmed by reverse transcription All studies used validated measures and patient satisfaction. JAMA In- ward noninferiority. polymerase chain reaction (RT-PCR), of physician burnout. tern Med. 2018;178(10):1317-30. BOTTOM LINE: For patients with the median time to alleviation of Burnout was associated with a ESBL E. coli or K. pneumoniae symptoms was lower in the baloxa- twofold increased risk of physi- No Pip/Tazo for patients blood stream infections, treatment vir group than it was in the placebo cian-reported safety incidents (odds 2 with ESBL blood stream with piperacillin/tazobactam was group (53.7 hours vs. 80.2 hours; P ratio, 1.96; 95% confidence interval, infections inferior to meropenem for 30-day less than .001). There was no signifi- 1.59-2.40), low professionalism (OR, mortality. cant difference in time to alleviation 2.31; 95% CI, 1.87-2.85), and likelihood CLINICAL QUESTION: Can pip- CITATION: Harris PNA et al. Ef- of symptoms in the baloxavir group of low patient-reported satisfaction eracillin/tazobactam be used as a fect of piperacillin-tazobactam vs when compared with the oseltami- (OR, 2.28; 95% CI, 1.42-3.68). There “carbapenem sparing” alternative in meropenem on 30-day mortality vir group. Adverse events were re- were no significant differences in patients with extended-spectrum for patients with E coli or Klebsiella ported in 21% of baloxavir patients, these results based on country of beta-lactamase (ESBL) Escherichia pneumoniae bloodstream infec- 25% of placebo patients, and 25% of origin of the study. Early-career coli or Klebsiella pneumoniae blood tion and ceftriaxone resistance: A oseltamivir patients. physicians were more likely to have stream infections? randomized clinical trial. JAMA. The enrolled patients were pre- burnout associated with low pro- BACKGROUND: ESBL-producing 2018;320(10):984-94. dominantly young, healthy, and January 2019 | 16 | The Hospitalist CLINICAL | In the Literature treated as an outpatient. Patients stroke. Patients with reduced life In a multivariate regression By Anne Linker, MD hospitalized with influenza pneumo- expectancy, dementia, or metastatic analysis, the investigators found Repeated qSOFA nia are often older, have significant cancer are less likely to benefit from no significant differences in inten- 5 measurements better comorbidities, and are at higher risk tight control. sification by life expectancy (P = predict in-hospital mortality of poor outcomes. This trial does not STUDY DESIGN: .07), diagnosis of dementia (P = .95), from sepsis directly support the safety or effica- Retrospective co- or metastatic malignancy (P = .13). cy of baloxavir in this population. hort study. There was a small increased prob- CLINICAL QUESTION: Do repeated BOTTOM LINE: A single dose of ba- SETTING: U.S. ability of intensification among quick Sepsis-Related Organ Failure loxavir provides similar clinical ben- Veterans Adminis- patients with heart failure, but no Assessment (qSOFA) measurements efit as 5 days of oseltamivir therapy tration (VA) Health such difference for patients with improve predictive validity for in the early treatment of healthy System. history of MI (P = .53), stroke (P = sepsis using in-hospital mortality, patients with acute influenza. SYNOPSIS: The .37), or renal disease (P = .73). compared with a single qSOFA mea- CITATION: Hayden FG et al. Baloxa- investigators re- The generalizability of this trial surement at the time a clinician first vir marboxil for uncomplicated in- Dr. Holzer viewed data from may be limited given the cohort was suspects infection? fluenza in adults and adolescents. N 14,915 adults over predominantly male (97%), white BACKGROUND: Sepsis in hospital- Eng J Med. 2018:379(10):914-23. 65 (median age, 76 years) admitted (77%), and 53% had at least four ma- ized patients is associated with poor to the VA with a diagnosis of pneu- jor comorbidities. outcomes, but it is not clear how to What drives intensification monia, urinary tract infection, or BOTTOM LINE: Intensification of best identify patients at risk. For 4 of antihypertensive therapy venous thromboembolism. Most antihypertensive therapy at dis- non-ICU patients, the qSOFA score at discharge? patients (65%) had well-controlled charge is often driven by inpatient (made up of three simple clinical blood pressure prior to admission. blood pressure readings rather than variables: respiratory rate greater CLINICAL QUESTION: Are decisions A total of 2,074 (14%) patients the broader context of their disease, than or equal to 22 breaths/minute, to intensify antihypertensive medi- were discharged with an intensi- such as prior long-term outpatient systolic blood pressure less than or cation regimens appropriate in older fied hypertension regimen (addi- blood pressure control or major co- equal to 100 mm Hg, and Glasgow hospitalized adults? tional medication or higher dose). morbidities. Coma Scale score less than 15) has BACKGROUND: Transient eleva- While both elevated inpatient and CITATION: Anderson TS et al. Inten- predictive validity for important tions in blood pressure are common outpatient blood pressures were sification of older adults’ outpatient outcomes including in-hospital among adult patients, yet there are predictive of intensification, the blood pressure treatment at hospital mortality. qSOFA is relatively new no data or guidelines that support association with elevated inpatient discharge: A national retrospective in clinical practice, and the optimal long-term medication changes based blood pressure was much stronger cohort study. BMJ. 2018:362:k3503. utilization of the score has not yet on these readings. Tight control of (odds ratio, 3.66; 95% confidence Dr. Holzer is an assistant professor of been defined. blood pressure is likely to improve interval, 3.29-4.08) than it was with medicine in the division of hospital STUDY DESIGN: Retrospective Co- outcomes among patients with heart elevated outpatient blood pressure medicine at Mount Sinai Hospital, hort Study. failure), myocardial infarction, and (OR, 1.75; 95% CI, 1.58-1.93). New York. Continued on following page

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the-hospitalist.org | 17 | January 2019 CLINICAL | In the Literature

Continued from previous page tals with a different sepsis case mix clinically significant extracranial complications was 96.6%, better SETTING: All adult medical and from the those of study institutions. bleeding) was higher in the aspirin than the goal of 88%. There was surgical encounters in the ED, hos- BOTTOM LINE: Repeated qSOFA group (P less than .001). In contrast improvement in quality of life, func- pital ward, postanesthesia care unit measurements improve predictive to prior studies, subgroup analysis tional capacity, severity of MR, and (PACU), and ICU at 12 hospitals in validity for in-hospital mortality for showed higher mortality in the left ventricular remodeling. Pennsylvania in 2012. patients with sepsis. Patients with aspirin group (attributed to an in- Limitations include that investiga- SYNOPSIS: Kievlan et al. studied low initial qSOFA scores have a low crease in the risk of cancer-related tors were not blinded because the de- whether repeated qSOFA scores chance (less than 2%) of in-hospital death.) The authors warn that this vice was visible on imaging. Longer improved prediction of in-hos- mortality. Further studies are needed finding should be interpreted with follow-up in the device group may pital mortality to determine how repeat qSOFA mea- caution. have contributed to the observed and allowed surements can be used to improve BOTTOM LINE: Aspirin use for pri- decreased mortality. It is unknown identification of management of patients with sepsis. mary prevention in healthy elderly whether less-symptomatic patients specific clinical CITATION: Kievlan DR et al. Evalua- persons over a 5-year period did not would attain the same benefit. trajectories. The tion of repeated quick sepsis-related change disability-free survival, did BOTTOM LINE: In patients with study included organ failure assessment measure- not decrease cardiovascular risk, symptomatic, moderate to severe, approximately ments among patients with suspect- and increased the rate of major and severe secondary MR, MVR low- 37,600 encounters. ed infection. Crit Care Med. 2018. doi: hemorrhage. ers rates of hospitalization, decreas- Authors abstract- 10.1097/CCM.0000000000003360. CITATIONS: McNeil JJ et al. Effect es mortality, and improves quality Dr. Linker ed demographic of aspirin on all-cause mortality in of life. data, vital signs, Daily aspirin use may not the healthy elderly. N Engl J Med. CITATION: Stone GW et al. Trans- laboratory results, and antibiotic/ 6 improve CV outcomes in 2018;379:1519-28. catheter mitral-valve repair in culture orders. An infection cohort healthy elderly Dr. Linker is an assistant professor of patients with heart failure. N Engl was identified by a combination of medicine in the division of hospital J Med. 2018 Sep 23. doi: 10.1056/NEJ- orders for body fluid culture and CLINICAL QUESTION: What are medicine at Mount Sinai Hospital, Moa1806640. antibiotics. The qSOFA scores were the benefits and risks of daily aspi- New York. gathered at 6-hour intervals from rin use for primary prevention in Same-day discharge after the culture/antibiotic event (sus- healthy elderly adults? By Aveena Kochar, MD 8 elective PCI has increased pected sepsis). Scores were low (0), BACKGROUND: Prior studies have Mitral valve repair improves value and patient satisfaction moderate (1), or high (greater than shown the efficacy of aspirin for 7 prognosis in heart failure or equal to 2). Mean initial qSOFA secondary prevention of cardiovas- patients with secondary MR CLINICAL QUESTION: What is the scores were greater for patients who cular disease and stroke, but the prevalence of same-day discharges died, and remained higher during evidence supporting the use of as- CLINICAL QUESTION: Does mitral (SDDs) for elective percutaneous the 48 hours after suspected infec- pirin for primary prevention is less valve repair (MVR) improve progno- coronary interventions (PCIs), and tion. Mortality was less than 2% in certain. sis in heart failure patients with sec- what is the effect on readmissions patients with an initial low qSOFA; STUDY DESIGN: Randomized, dou- ondary mitral regurgitation (MR)? and hospital cost? 25% of patients with an initial mod- ble-blind, placebo-controlled pro- BACKGROUND: In patients with BACKGROUND: SDDs are as safe as erate qSOFA had subsequent higher spective study with a 5-year study primary degener- non-SDDs (NSDDs) in patients after qSOFAs, and they had higher mor- period. ative MR, MVR is elective PCI, yet there has been only tality, compared with patients with SETTING: Australia and the United curative, with the a modest increase in SDD. subsequent low qSOFA scores (16% States. transcatheter ap- STUDY DESIGN: Observational vs. 4%). SYNOPSIS: The Aspirin in Reduc- proach being safer cross-sectional cohort study. Only those patients with initial ing Events in the Elderly (ASPREE) than surgical re- SETTING: 493 hospitals in the Unit- qSOFA scores at the time of sus- trial included 19,114 community- pair. However, it is ed States. pected infection were included, and dwelling healthy people (aged 70 unknown whether SYNOPSIS: With use of the nation- missing data were common. The re- years and older overall and aged 65 patients with sec- al Premier Healthcare Database, sults may not be applicable to hospi- years and older if black or Hispan- Dr. Kochar ondary MR from 672,470 elective PCIs from Janu- ic), without cardiovascular disease, left ventricular ary 2006 to December 2015 with Short Takes dementia, or disability. The goal dilatation would confer the same 1-year follow-up showed a wide was to investigate the effect of dai- benefit of MVR. variation in SDD from 0% to 83% Restrictive transfusion ly low-dose aspirin (100 mg, enteric STUDY DESIGN: Multicenter, ran- among hospitals with the overall strategy for cardiac surgery coated) on healthy life span (with- domized, controlled, parallel-group, corrected rate of 3.5%. Low-volume patients remains noninferior out dementia or disability), with open-label trial. PCI hospitals did not increase the at 6 months post op prespecified secondary outcomes SETTING: 78 sites in the United rate. Additionally, the cost of SDD The authors previously reported (cardiovascular events and major States and Canada. patients was $5,128 less than NSDD that, in moderate- to high-risk hemorrhage). SYNOPSIS: From December 2012 patients. There was cost saving cardiac surgery patients, a restric- Analysis was by intention to to June 2017, 614 patients from 78 even with higher-risk transfemoral tive transfusion strategy was treat. Participants were predomi- centers in the United States and approaches and patients needing noninferior to a liberal strategy nantly white, approximately 10% Canada with symptomatic MR were periprocedural hemodynamic or based on the clinical outcomes of patients had diabetes, 74% had enrolled with 302 patients assigned ventilatory support. Complications of all-cause mortality, MI, stroke, hypertension, and 65% had dyslip- to the device group (transcatheter (death, bleeding, acute kidney in- or new renal failure with dialysis. idemia. There was high adherence MVR and medical treatment) and 312 jury, or acute MI at 30, 90, and 365 The groups continued to show no to the intervention. There was no to the control group (medical thera- days) were not higher for SDD than significant difference in outcomes significant difference in the prima- py). Over 2 years, the device group’s for NSDD patients. at 6 months post op. ry outcome (disability-free survival) annual rate for heart failure hospi- Limitations include that 2015 data CITATION: Mazer CD et al. or in the secondary outcome of car- talizations was significantly lower may not reflect current practices. Six-month outcomes after restric- diovascular event (fatal or nonfatal (35.8%/patient-year versus 67.9%/ ICD 9 codes used for obtaining tive or liberal transfusion for MI or stroke, or hospitalization for patient-year in the control group), complications data can be misclas- cardiac surgery. N Engl J Med. heart failure.) The rate of major as was all-cause mortality (29.1% for sified. Cost savings are variable. 2018;379:1224-33. hemorrhage (hemorrhagic stroke, the device group versus 46.1%). The Patients with periprocedural com- symptomatic intracranial bleeding, rate of freedom from device-related plications were not candidates January 2019 | 18 | The Hospitalist CLINICAL | In the Literature for SDD but were included in the BACKGROUND: In its Pay for Per- admission by 9.6%, changed rates comes have not been assessed. data. The study does not account formance program, Medicare ties upward or downward by 0.4%-0.7% STUDY DESIGN: Observational fol- for variation in technique, PCI payments to readmission rates but for the 10% of hospitals most af- low-up. characteristics, or SDD criteria of adjusts these rates fected by the readjustments, and SETTING: Six hospitals in Finland. hospitals. only for limited they would be expected to reduce SYNOPSIS: The APPAC trial looked BOTTOM LINE: Prevalence of SDDs patient character- penalties by 52%, 46%, and 41% for at 530 patients, aged 18-60 years, for elective PCI patients varies by istics. Hospitals hospitals with the largest 1%, 5%, with CT-confirmed acute uncom- institution and is an underutilized serving higher-risk and 10% of penalty reductions, re- plicated appendicitis, who were opportunity to significantly reduce patients have spectively. randomized to receive either ap- hospital costs and increase patient received greater BOTTOM LINE: Hospitals serving pendectomy or antibiotics. In this satisfaction while maintaining the penalties. These higher-risk patients may be penal- follow-up report, outcomes were safety of patients. programs may ized because of the patients they assessed by telephone interviews CITATION: Amin AP et al. Associ- Dr. Asuen have the unintend- serve rather that the quality of care conducted 3-5 years after the ini- ation of same-day discharge after ed consequence they provide. tial interventions. Overall, 100 of elective percutaneous coronary in- of penalizing hospitals that provide CITATION: Roberts ET et al. Assess- 256 (39.1%) of the antibiotic group tervention in the United States with care to higher-risk patients. ment of the effect of adjustment for ultimately underwent appendecto- costs and outcomes. JAMA Cardiol. STUDY DESIGN: Observational patient characteristics on hospital my within 5 years. Of those, 70/100 Published online 2018 Sep 26. doi: study. readmission rates: Implications for (70%) had their recurrence within 1 10.1001/jamacardio.2018.3029. SETTING: Medicare admissions Pay for Performance. JAMA Intern year of their initial presentation. Dr. Kochar is an assistant professor of claims from 2013 through 2014 in Med. 2018;178(11)1498-507. BOTTOM LINE: Patients with un- medicine in the division of hospital 2,215 hospitals. complicated appendicitis treated medicine at Mount Sinai Hospital, SYNOPSIS: Using Medicare claims Uncomplicated with antibiotics have a 39% cumu- New York. for admission and linked U.S. 10 appendicitis can be lative 5-year recurrence rate, with census data, the study assessed treated successfully with most recurrences occurring within By Imuetinyan Asuen, MD several clinical and social charac- antibiotics the first year. Adjustment for teristics not currently used for risk CITATION: Salminem P et al. Five- 9 characteristics not used adjustment. A sample of 1,169,014 CLINICAL QUESTION: What is the year follow-up of antibiotic therapy by Medicare reduces hospital index admissions among 1,003,664 late recurrence rate for patients for uncomplicated acute appendici- variations in readmission rates unique beneficiaries was analyzed. with uncomplicated appendicitis tis in the APPAC Randomized Clini- The study compared rates with treated with antibiotics only? cal Trial. JAMA. 2018;320(12):1259-65. CLINICAL QUESTION: Can differ- and without these additional ad- BACKGROUND: Short-term results Dr. Asuen is an assistant professor of ences in hospital readmission rates justments. support antibiotic treatment as medicine in the division of hospital be explained by patient characteris- Additional adjustments reduced alternative to surgery for uncompli- medicine at Mount Sinai Hospital, tics not accounted for by Medicare? overall variation in hospital re- cated appendicitis. Long-term out- New York.

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the-hospitalist.org | 19 | January 2019 CLINICAL | In the Literature

Pediatric ITL Public insurance income limits and hospitalizations for low-income children Vulnerable populations at greater risk

By Alissa Darden, MD decreasing income eligibility thresh- federal poverty level (FPL), includ- olds. As a result, many children ing less than 100%, less than 200%, BACKGROUND: Medicaid and the from low-income families would and less than 300%. Of the families Children’s Health Insurance Pro- lose their public insurance and be included, 43% lived below 300%, 27% gram (CHIP) provide health care eligible for commercial insurance below 200%, and 11% below 100% of to over 30 million children in the only. Consequently, this would place the FPL. Of note, public insurance United States.1,2 As a result, low-in- an undue financial burden on these FPL eligibility limits tended to be come children have had increased families and the health care systems lower in states with a greater per- access to health care, of all forms, that care for them. Furthermore, it centage of the population being be- which has increased the utilization is anticipated that poor health care low 300% of the FPL. The results, of of primary care and decreased un- outcomes would increase in these these reductions, were as follows: necessary ED visits and hospitaliza- vulnerable populations. • If reduced to less than 300% of the tions. However, this comes at a high STUDY DESIGN: Retrospective FPL, about 155,000 hospitalizations cost, both at the state and national cohort study using 2014 State Inpa- became ineligible for reimburse- level. Medicaid currently subsidiz- tient Databases. ment. The median per-hospitaliza- es more than 50% of every state’s SETTING: Pediatric hospitalizations tion estimated costs ranged from public insurance program, spending (aged less than 18 years) from 14 approximately $6,000 to approxi- about $100 billion/year in health states during 2014 with public in- mately $10,000, accumulating $1.2 care payments for children.3 Giv- surance listed as the primary payer. billion in estimated costs. en this hefty price tag, there have This encompassed about 30% of • If reduced to less than 200% been myriad strategies proposed to family households in the United of the FPL, about 440,000 hos- help decrease these costs. One such States in 2014. pitalizations became ineligible strategy, includes decreasing enroll- SYNOPSIS: Simulations were done for reimbursement. The median Dr. Darden is a pediatric hospitalist ment in public insurance through at three different thresholds of the per-hospitalization estimated at Phoenix Children’s Hospital and costs ranged from approximately clinical assistant professor, Universi- $2,000 to approximately $10,000, ty of Arizona, Phoenix. accumulating $3.1 billion in esti- mated costs. • If reduced to less than 100% of burden will shift to the institutions the FPL, about 650,000 hospi- that care for these vulnerable popu- talizations became ineligible for lations. reimbursement. The median BOTTOM LINE: If public insurance per-hospitalization estimated eligibility thresholds were de- costs ranged from approximately creased, a large number of pediatric $2,000 to approximately $10,000, hospitalizations would become ineli- accumulating $4.4 billion in esti- gible for coverage, which would shift mated costs. the costs to families and institutions SHM Chapters If these reductions occurred, that are already financially strained healthy newborns would be dis- and likely result in poor health care World-class networking and proportionately affected by them, outcomes for some of our most vul- which is important to note because nerable pediatric patients. education in your backyard. newborn hospitalization is one of CITATION: Bettenhausen JL et the fastest-rising costs in pediatric al. The effect of lowering public care. In fact, it can range from ap- insurance income limits on hospi- proximately $700 to approximately talizations for low-income children. $2,000 per hospitalization, which Pediatrics. 2018 Aug. doi: 10.1542/ may represent a huge financial peds.2017-3486. strain for families that are unable Connect with other hospital medicine professionals to secure commercial insurance. References in your area at in-person meetings or online in your Furthermore, with the average 1. The Henry J. Kaiser Family Foundation. Total chapter’s HMX community. hospitalization of non-newborns Medicaid Spending. 2016. Available at http:// ranging from $3,000 to $10,000, it is kff.org/medicaid/state-indicator/total-medic- likely that this cost would consti- aid-spending/. Connect to your chapter • hospitalmedicine.org/chapters tute a fairly large percentage of a 2. Medicaid and CHIP Payment and Access Commission. Trends in Medicaid Spending. low-income family’s annual income, 2016. Available at https://www.macpac.gov/ which may represent an untenable wp-content/uploads/2016/06/Trends-in-Med- financial burden. icaid-Spending.pdf. Thus, if these families are unable 3. Medicaid and CHIP Payment and Access Commission. Medicaid’s share of state budg- to obtain commercial insurance and/ ets. 2017. Available at https://www.macpac.gov/ or pay these debts, the financial subtopic/medicaids-share-of-state-budgets/. January 2019 | 20 | The Hospitalist CLINICAL ASH releases new VTE guidelines

By Mitchel L. Zoler a direct-acting oral anticoagulant, against bridging therapy with cates that additional guidelines will MDedge News both during hospitalization and LMWH for most patients who need soon be released on management following discharge. The guidelines to stop warfarin when undergoing of VTE in patients with cancer and he American Society of for prevention in medical patients an invasive procedure. The guide- in patients with thrombophilia, and Hematology has released a explicitly “recommended against” lines also called for “thoughtful” use for prophylaxis in surgical patients, new set of guidelines for the using a direct-acting oral anticoagu- of anticoagulant reversal agents and as well as further information on prevention, diagnosis, and lant “over other treatments” both for advised that patients who survive treatment. A spokesperson for ASH Tmanagement of venous thromboem- hospitalized medical patients and a major bleed while on anticoagula- said that these additional docu- bolism. after discharge, and the guidelines tion should often resume the antico- ments will post sometime in 2019. The guidelines contain more than further recommend against extend- agulant once they are stabilized. At the time of the release, the 150 individual recommendations, ed prophylaxis after discharge with For patients who develop heparin- guidelines panel published six arti- including sections devoted to manag- any other anticoagulant. induced thrombocytopenia, the 4Ts cles in the journal Blood Advances ing venous thromboembolism (VTE) Another important takeaway from score is the best way to make a more that detailed the guidelines and during pregnancy and in pediatric the prevention section was a state- accurate diagnosis and boost the their documentation. patients. Guideline highlights cited ment that combining both mechan- prospects for recovery, said Dr. Cuker The articles include prophylaxis by some of the writing-panel par- ical and medical prophylaxis was (Blood. 2012 Nov 15;120[20]:4160-7). The of medical patients (Blood Advanc- ticipants included a high reliance not needed for medical inpatients. guidelines cite several agents now es. 2018 Nov 27;2[22]:3198-225), diag- on low-molecular-weight heparin And once patients are discharged, if available to treat this common com- nosis (Blood Advances. 2018 Nov (LMWH) agents as the preferred they take a long air trip they have plication, which affects about 1% of 27;2[22]:3226-56), anticoagulation treatment for many patients, reliance no need for compression stockings the 12 million Americans treated with therapy (Blood Advances. 2018 Nov on the -dimer test to rule out VTE or aspirin if their risk for throm- heparin annually: argatroban, bivali- 27;2[22]:3257-91), pediatrics (Blood in patients with a low pretest proba- bosis is not elevated. People with a rudin, danaparoid, fondaparinux, Advances. 2018 Nov 27;2[22]:3292-316), bility of disease, and reliance on the “substantially increased” thrombosis apixaban, dabigatran, edoxaban, and pregnancy (Blood Advances. 2018 4Ts score to identify patients with risk “may benefit” from compression rivaroxaban. Nov 27;2[22]:3317-59), and heparin-in- heparin-induced thrombocytopenia. stockings or treatment with LMWH, ASH has a VTE website with links duced thrombocytopenia (Blood Ad- The guidelines took more than 3 Dr. Cushman said. to detailed information for each of vances. 2018 Nov 27;2[22]:3360-92). years to develop, an effort that be- the guideline subcategories: prophy- Dr. Cushman, Dr. Lim, and Dr. gan in 2015. Diagnosis laxis in medical patients, diagnosis, Witt reported having no relevant An updated set of VTE guidelines For diagnosis, Wendy Lim, MD, high- therapy, heparin-induced thrombo- disclosures. Dr. Cuker reported re- were needed because clinicians now lighted the need for first categoriz- cytopenia, VTE in pregnancy, and ceiving research support from T2 have a “greater understanding of risk ing patients as having a low or high VTE in children. The website indi- Biosystems. factors” for VTE as well as having probability for VTE, a judgment that “more options available for treating can aid the accuracy of the diag- VTE, including new medications,” nosis and helps avoid unnecessary Adam C. Cuker, MD, cochair of the testing. guideline-writing group and a hema- For patients with low pretest REGISTER NOW! tologist and thrombosis specialist probability, the guidelines recom- at the University of Pennsylvania, mended the -dimer test as the best ENCORE AT WYNN Philadelphia, said during a webcast first step. Further testing isn’t need- LAS VEGAS to unveil the new guidelines. ed when the -dimer is negative, FEBRUARY 25 28, 2019 noted Dr. Lim, a hematologist and ENHANCED RECOVERY PROGRAM Prevention professor at McMaster University, Earn up to 29 CME Credits FEBRUARY 25 26, 2019 Including Optional MOC Self-Assessment Credit For preventing VTE in hospitalized Hamilton, Ont. medical patients the guidelines The guidelines also recommended The premier meeting of thought leaders in recommended initial assessment using ventilation-perfusion scin- of the patient’s risk for both VTE tigraphy (V/Q scan) for imaging a minimally invasive surgery and enhanced recovery and bleeding. Patients with a high pulmonary embolism over a CT TOPICS bleeding risk who need VTE preven- scan, which uses more radiation. But tion should preferentially receive V/Q scans are not ideal for assessing · Enhanced Recovery after Surgery mechanical prophylaxis, either older patients or patients with lung · A to Z Enhanced Recovery compression stockings or pneumatic disease, Dr. Lim cautioned. Implementation sleeves. But in patients with a high · Colon VTE risk and an “acceptable” bleed- Management · Hernia ing risk, prophylaxis with an antico- Management of VTE should occur, · Foregut agulant is preferred over mechanical when feasible, through a special- · Metabolic/Bariatric measures, said Mary Cushman, MD, ized anticoagulation management professor and medical director of service center, which can provide EXECUTIVE DIRECTOR the thrombosis and hemostasis pro- care that is best suited to the com- Philip R. Schauer, MD gram at the University of Vermont, plexities of anticoagulation therapy. Burlington. But it’s a level of care that many U.S. Cleveland Clinic

For prevention of VTE in medical patients don’t currently receive and Flexible registration options available inpatients, LMWH is preferred over hence is an area ripe for growth, For more information and to register go to: MISS-CME.org unfractionated heparin because said Daniel M. Witt, PharmD, profes- of its once-daily dosing and fewer sor and vice-chair of pharmacother- This educational program is not complications, said Dr. Cushman, a apy at the University of Utah, Salt Jointly Provided by aliated with the Society of member of the writing group. The Lake City. Hospital Medicine panel also endorsed LMWH over The guidelines recommended the-hospitalist.org | 21 | January 2019 Make your next smart move. Visit shmcareercenter.org.

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Hospitalist Regional Medical Director Opportunities in Eastern PA – Starting Bonus and Loan Repayment – Chicago—Vibrant City, St. Luke’s University Health Network (SLUHN) is interviewing for Family Friendly Suburbs Hospitalist Regional Medical Director Candidates for our growing 10-hospital network. This is an opportunity to lead a dynamic IMMEDIATE OPENINGS-Advocate Medical group of physicians at several campuses, engage them as a team and work to assure consistent high quality. All campuses Group (AMG), a part of Advocate Health have a closed ICU, strong advanced practitioner assistance and all specialty back up, in addition to an opportunity for upward Care, is actively recruiting HOSPITALISTS for mobility within the Network. To advertise in growing teams across metro Chicago. SLUHN is a non-profit network comprised of physicians and 10 hospitals, providing care in eastern Pennsylvania and western The Hospitalist or the • Flexible 7 on7 off scheduling NJ. We employ more than 800 physician and 200 advanced Journal of Hospital Medicine practitioners. St. Luke’s currently has more than 220 physicians • Manageable daily census enrolled in internship, residency and fellowship programs and is • Established, stable program with a regional campus for the Temple/St. Luke’s School of Medicine. Visit www.slhn.org Contact: 90+ providers • First-rate specialist support We offer: Heather Gonroski • Starting bonus and up to $100,000 in loan repayment 973.290.8259 • Comprehensive benefits, relocation & • 7 on/7 off schedules • Additional stipend for nights [email protected] CME allowance • Attractive base compensation with incentive • Excellent benefits, including malpractice, or Advocate Medical Group is part of moving expenses, CME Linda Wilson • Moonlighting Opportunities within the Network Advocate Aurora Health – the 10th largest 973.290.8243 not-for-profit health system in the nation. Our campuses offer easy access to major cities like NYC and [email protected] Philadelphia. Cost of living is low coupled with minimal congestion; Submit CV & cover letter to choose among a variety of charming urban, semi-urban and rural communities your family will enjoy calling home. For more information [email protected] visit www.discoverlehighvalley.com Tomorrow starts today. Please email your CV to Drea Rosko at [email protected] January 2019 | 22 | The Hospitalist Make your next smart move. Visit shmcareercenter.org.

Chief of Hospitalist Medicine Opportunity in Northeast Pennsylvania

Job description: QOversees the development of the annual budget and key operating indicators for the Guthrie Clinic, a non-profit, physician-led, integrated health care delivery system is Department and monitors the Department’s performance in relation to these annual seeking candidates for Chief, Section of Hospitalist Medicine. The Chief will oversee 24 targets. Hospitalists and 9 Advanced Practice Providers, located in 4 regional hospitals. The Chief QWorks collaboratively with the Program Director for the Internal Medicine Residency has responsibility for quality, leadership, scheduling and overall program strategy. Program, the Fellowship Directors and the Director of Medical Education to ensure that the quality of the residency and fellowship(s). Position details and requirements: Q Q M.D. or D.O.; BC in Internal Medicine. Advanced degree (MBA, MHA, MMM) desirable. Ensures the Section functions in an integrated system of care, improving performance, QFive or more years of successfully leading a Hospitalist program. growing depth of clinical programs, and enhancing quality outcomes. QStrong commitment to the patient care and future academic missions of QServes as mentor, guide and support for Hospitalists system wide. Q Guthrie Clinic. Leads recruitment/retention of physicians and APPs to actively grow the Section. QPossession of, or eligibility for, a medical license in Pennsylvania. QPosition is 50% Administrative and 50% clinical. Clinical Guthrie, founded in 1910, provides comprehensive team-based care to patients from an • Participates in quality and system improvement within group and across hospital. 11-county service area. Guthrie Clinic is comprised of four hospitals, 500 physicians and • Participates in all group clinical decisions with the goal of high quality care. advanced practice providers in a regional office network made up of 45 sub-specialty • Participates in group performance reviews with regard to quality of care, satisfaction, and primary care sites in 21 communities. In addition, we offer a wide range of services and efficiency metrics. and programs including home health and home care services, GME and a research • Coordinates schedule with group to maintain 24/7 coverage at all hospitals within the institute. Guthrie was the first system to implement EPIC EMR, in 2002, with the go-live integrated health system. of Epic CPOE (Certified Physician Order Entry). • Ensures coverage of shifts. Guthrie's (main) Sayre campus is situated in a beautiful valley in north-central PA, Administrative located just a few miles from the NY border. Guthrie’s service area stretches from • Participates in strategic plan for hospital medicine group, including marketing, growth/ Corning and Ithaca, NY to Wellsboro, PA (home of PA Grand Canyon) down to recruiting, service, and quality. Tunkhannock, PA and is less than 30 minutes from the Finger Lakes region. • Establish annual goals for quality, efficiency growth and satisfaction. • Responsible for developing, updating and maintaining clinical standards and care For more information about this leadership opportunity, please contact Krisi VanTassel paths. at [email protected] or (570) 887-5203, www.ichoseguthrie.org. • Participates in utilization review and peer review activities as they relate to the Hospitalist program.

ichoseguthrie.org

the-hospitalist.org | 23 | January 2019 Make your next smart move. Visit shmcareercenter.org.

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)DFLOLWLHV x Relocation Assistance %DOODG+HDOWK6RXWKZHVW9LUJLQLD x Teaching and Faculty Opportunities with System Residency Programs Johnston Memorial Hospital, Russell County Medical Center, Smyth County x Critical Care Physician Coverage in most of the facilities CCU/PCUs Community Hospital, Norton Community Hospital, Mountain View Regional x Opportunity to Participate in Award-Winning Quality Improvement Projects Medical Center, Lonesome Pine Hospital

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Physician-Led Medicine in Montana Internal Medicine/Family Medicine ICU Hospitalist/Nocturnist CHA Everett Hospital Cambridge Health Alliance (CHA) is a well-respected, nationally Hospitalist recognized and award-winning public healthcare system, which receives recognition for clinical and academic innovations. Our system is comprised of three hospital campuses in Cambridge, Somerville and Everett with additional outpatient clinic locations throughout Boston’s Metro North Region. CHA is an academic affiliate of both Harvard Medical School (HMS) and Tufts University School of Medicine. We are a clinical affiliate of Beth Generous loan repayment Israel Deaconess Medical Center. Seeking a BE/BC Hospitalist CHA is recruiting for an ICU Hospitalist/Nocturnist to cover Everett Hospital. and a Nocturnist to join our • Position requires PM shifts (7p-7a) plus weekend day shifts group in Montana’s premier, • Work collaboratively with CHA’s intensivist MDs to round on inpatients state-of-the-art medical within the CHA Everett Hospital ICU center, which serves as the • Cross coverage of med/surg inpatient unit included as part of clinical region’s tertiary referral responsibility (10% of total FTE) center. Our seasoned team • Applicants should be comfortable with procedures including central values work-life balance lines, vent management, intubation, etc. and collegiality. • Internal training and maintenance program exists to assist in certification of these skills competencies To advertise in • Extremely flexible • scheduling Academic appointment is available commensurate with medical school or the criteria The Hospitalist • Shifts reduced for Nocturnist Billings Clinic is nationally Applicants should be trained and Board Certified in Internal Medicine or Journal of Hospital Medicine recognized for clinical Family Medicine and possess excellent clinical and communication skills • Generous salary with plus a demonstrated commitment to CHA’s multicultural, underserved yearly bonus excellence and is a proud member of the Mayo Clinic patient population. • Signing bonus At CHA, we have a supportive and collegial clinical environment with strong • No procedures required Care Network. Located in Billings, Montana – this leadership, infrastructure. CHA has a fully integrated electronic medical CONTACT: • J-1 waivers accepted friendly college community is record system (Epic) throughout our inpatient units and outpatient clinics. We offer a competitive, guaranteed base salary and comprehensive benefits • “Top 10 Fittest Cities in a great place to raise a family Heather Gonroski America 2017” – Fitbit package. near the majestic Rocky 973.290.8259 • “America’s Mountains. Please visit www.CHAproviders.org to learn more and apply through our secure candidate portal. CVs may be sent directly to Lauren Anastasia, Manager, [email protected] Best Town Exciting of 2016” CHA Provider Recruitment via email at [email protected]. CHA’s outdoor or Contact: Rochelle Woods Department of Provider Recruitment may be reached by phone at (617) 665- recreation 3555 or by fax at (617) 665-3553. Linda Wilson 1-888-554-5922 close to We are an equal opportunity employer and all qualified applicants will receive 973.290.8243 physicianrecruiter@ home. 300 billingsclinic.org consideration for employment without regard to race, color, religion, sex, sexual [email protected] days of orientation, gender identity, national origin, disability status, protected veteran billingsclinic.com sunshine! #1 in Montana status, or any other characteristic protected by law. January 2019 | 24 | The Hospitalist Make your next smart move. Visit shmcareercenter.org.

ENVISION PHYSICIAN SERVICES OFFERS ... THE SUPPORT I NEED TO GROW AS A e icia A eade .

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the-hospitalist.org | 25 | January 2019 Make your next smart move. Visit shmcareercenter.org.

H OSPITALIST AND N OCTURNIST P OSITION A VAILABLE Location, Location, Location Joy. Make it part of your career.

Vituity provides the support and resources you need to focus on the joy of healing.

We currently have opportunities for hospitalists and intensivists at hospitals and skilled nursing practices across the country. Some with sign-on bonuses up to $100,000!

Concord :30 Boston

Come join our well established hospitalist team of dedicated Emerson Hospital provides advanced medical services hospitalist at Emerson Hospital located in historic Concord, to more than 300,000 people in over 25 towns. We are a Massachusetts. Enjoy living in the suburbs with convenient 179 bed hospital with more than 300 primary care doctors access to metropolitan areas such as Boston, New York and and specialists. Our core mission has always been to make Providence as well as the mountains, lakes and coastal areas. high-quality health care accessible to those that live and work Opportunities available for hospitalist and nocturnists; full in our community. While we provide most of the services time, part time, per diem and moonlighting positions, just that patients will ever need, the hospitals strong clinical 25 minutes from Boston. A great opportunity to join a well collaborations with Boston’s academic medical centers established program. ensures our patients have access to world-class resources for more advanced care. For more information please • Manageable daily census contact: Diane M Forte, Director of Physician Recruitment • Flexible scheduling to ensure work life balance and Relations 978-287-3002, [email protected] • Dedicated nocturnist program • Intensivists coverage of critical care unit Not a J-1 of H1B opportunity • Competitive compensation and bonus structure • Comprehensive benefit package including CME allowance • Access to top specialty care

EMERSONHOSPITAL . 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 IM/FM trained physicians interested in joining the Penn State Health family in various settings within our system. California What We’re Offering: • Community Setting Hospitalist opportunities (Lancaster and Berks County positions) • Fresno • Redding • San Jose • We’ll foster your passion for patient care and cultivate a • Modesto • San Diego • San Mateo collaborative environment rich with diversity • Commitment to patient safety in a team approach model Illinois Missouri Oregon • Experienced hospitalist colleagues and collaborative • Belleville • St. Louis • Eugene leadership • Greenville • Salary commensurate with qualifications • Relocation Assistance Interested in travel? What We’re Seeking: Check out our Reserves Program. • Internal Medicine or Family Medicine trained • Ability to acquire license in the State of Pennsylvania • Must be able to obtain valid federal and state narcotics Future leader? certificates Apply for our Administrative Fellowship. • Current American Heart Association BLS and ACLS certification required • BE/BC in Family Medicine or Internal Medicine (position dependent) We proudly sponsor visa candidates! No J1 visa waiver sponsorships available For more information, please contact us at What the Area Offers: [email protected]. 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.

January 2019 | 26 | The Hospitalist Make your next smart move. Visit shmcareercenter.org.

HOSPITALISTS/ NOCTURNISTS NEEDED IN SOUTHEAST LOUISIANA

Ochsner Health System is seeking physicians to join our hospitalist team. BC/BE Internal Medicine and Family Medicine physicians are welcomed to apply. Highlights of our opportunities are: yHospital Medicine was established at Ochsner in 1992. We have a stable 50+ member group y7 on 7 off block schedule with flexibility yDedicated nocturnists cover nights yBase plus up to 45K in incentives yAverage census of 14-18 patients yE-ICU intensivist support with open ICUs at the community hospitals yEPIC medical record system with remote access capabilities yDedicated RN and Social Work Clinical Care Coordinators yCommunity based academic appointment yThe only Louisiana Hospital recognized by US News and World Report Distinguished Hospital for Clinical Excellence award in 4 medical specialties yCo-hosts of the annual Southern Hospital Medicine Conference yWe are a medical school in partnership with the University of Queensland providing clinical training to third and fourth year students yLeadership support focused on professional development, quality improvement, and

yOpportunities for leadership development, research, resident and medical student teaching y Hospitalist Opportunity Available Skilled nursing and long term acute care facilities seeking hospitalists and mid-levels with Join the Healthcare Team at an interest in geriatrics Berkshire Health Systems! yPaid malpractice coverage and a favorable malpractice environment in Louisiana yGenerous compensation and benefits package Berkshire Health Systems is currently seeking BC/BE Internal Medicine physicians to join our 2FKVQHU+HDOWK6\VWHPLV/RXLVLDQD·VODUJHVWQRQSURILWDFDGHPLFKHDOWKFDUHV\VWHP comprehensive Hospitalist Department Driven by a mission to Serve, Heal, Lead, Educate and Innovate, coordinated clinical and • Day, Evening and Nocturnist positions KRVSLWDOSDWLHQWFDUHLVSURYLGHGDFURVVWKHUHJLRQE\2FKVQHU·VRZQHGPDQDJHGDQG • Previous Hospitalist experience is preferred affiliated hospitals and more than 80 health centers and urgent care centers. Ochsner is Located in Western Massachusetts Berkshire orld Report as a “Best Hospital” Medical Center is the region’s leading provider of across four specialty categories caring for patients from all 50 states and more than 80 comprehensive health care services countries worldwide each year. Ochsner employs more than 18,000 employees and over • 302-bed community teaching hospital with 1,100 physicians in over 90 medical specialties and subspecialties, and conducts more than residency programs 600 clinical research studies. For more information, please visit ochsner.org and follow us on • A major teaching affiliate of the University of Twitter and Facebook. Massachusetts Medical School and UNECOM • Geographic rounding model Interested physicians should email their CV to [email protected] • A closed ICU/CCU or call 800-488-2240 for more information. • A full spectrum of Specialties to support the team • 7 on/7 off 10 hour shift schedule Reference # SHM2017. We understand the importance of balancing work with a healthy personal lifestyle Sorry, no opportunities for J1 applications. • Located just 2½ hours from Boston and New York City • Small town New England charm Ochsner is an equal opportunity employer and all qualified applicants will receive consideration for • Excellent public and private schools employment without regard to race, color, religion, sex, national origin, sexual orientation, disability • World renowned music, art, theater, and museums status, protected veteran status, or any other characteristic protected by law • Year round recreational activities from skiing to kayaking, this is an ideal family location. Berkshire Health Systems offers a competitive salary and benefits package, including relocation. To learn more, visit www.the-hospitalist.org and

Interested candidates are invited to contact: click “Advertise” or contact Liz Mahan, Physician Recruitment Specialist, Berkshire Health Systems Heather Gonroski • 973-290-8259 • [email protected] or 725 North St. • Pittsfield, MA 01201 • (413) 395-7866. Linda Wilson • 973-290-8243 • [email protected] Applications accepted online at www.berkshirehealthsystems.org

the-hospitalist.org | 27 | January 2019 Make your next smart move. Visit shmcareercenter.org.

UNIVERSITY OF MICHIGAN DIVISION OF HOSPITAL MEDICINE

7KH8QLYHUVLW\RI 0LFKLJDQ'LYLVLRQRI +RVSLWDO0HGLFLQHVHHNVERDUGFHUWLÀHGERDUGHOLJLEOHLQWHUQLVWVWRMRLQ our growing and dynamic division. Hospitalist duties include teaching of medical residents and students, direct patient care in our non-resident and short-stay units and involvement in quality improvement and patient safety LQLWLDWLYHV1RYHOFOLQLFDOSODWIRUPVWKDWIHDWXUHVSHFLDOW\FRQFHQWUDWLRQV KHPDWRORJ\RQFRORJ\VHUYLFHUHQDO transplant service and bone marrow transplant teams) as well as full-time nocturnist positions are also available. Our medical short stay unit provides care for both observation and inpatient status patients and incorporates advanced practice providers as part of the medical team.

7KHLGHDOFDQGLGDWHZLOOKDYHWUDLQHGDWRUKDYHFOLQLFDOH[SHULHQFHDWDPDMRU86DFDGHPLFPHGLFDOFHQWHU6SRQVRUVKLSRI +% and green cards is considered on a case-by-case basis for outstanding individuals. Research opportunities and hospitalist investigator SRVLWLRQVDUHDOVRDYDLODEOHIRUTXDOLÀHGFDQGLGDWHV

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Live. Hospitalists and Nocturnists Opportunities Available

Your work is your passion. But it’s not your whole life. Join a system that supports your need to balance work and home life. You can find great dining, art, entertainment, and culture in our cities, as well as peace and quiet in our rural areas. With opportunity for advancement and great schools and colleges nearby, it’s a great place to grow your career and your family. UPMC Pinnacle — a growing, multisite health system in south central Pennsylvania — Work . can meet your needs at one of our eight acute care hospitals

Join our Hospitalist Team Q Traditional block and flexible schedules Q Closed and open ICU environments available with options for procedures and dedicated code teams Q Competitive salary — above MGMA median salary Q Additional compensation for nocturnist and ICU coverage Balance. Q Strong advanced practice provider support at all locations Q Great administrative and clinical leadership support

Schedule a call with our recruiter today! Contact Rachel Jones, MBA, FASPR Physician Recruiter [email protected] 717-231-8796

UPMCPinnacle.com/Providers

UPMC Pinnacle is an Equal Opportunity Employer. EOE

January 2019 | 28 | The Hospitalist Make your next smart move. Visit shmcareercenter.org.

Maximize your Career with Emory’s Premier Academic Hospital Medicine Division

The Division of Hospital Medicine at the Emory University School of Medicine and Emory Healthcare is currently seeking exceptional individuals to join our highly respected team of physicians and medical directors. Ideal candidates will be BC/BE internists who possess outstanding clinical and interpersonal skills and who envision a fulfilling career in academic hospital medicine. Emory hospitalists have opportunities to be involved in teaching, quality improvement, patient safety, health services research, and Our Programs: other professional activities. Our hospitalists have access to faculty development programs within the Emory University Hospital Division and work with leaders focused on mentoring, medical education, and fostering research. Emory University Hospital Midtown Emory University Orthopaedics & Spine Hospital Emory Saint Joseph’s Hospital We are recruiting now for both Nocturnist and Daytime positions, so apply today. Applications will be Emory Johns Creek Hospital considered as soon as they are received. Emory University is an Equal Opportunity Employer. Emory Decatur Hospital Emory Hillandale Hospital Grady Memorial Hospital A career with Emory includes: Apply now for immediate openings! Veterans Affairs Medical Center, Atlanta • Generous salary, benefits, and incentives Email your cover letter and CV to: • Faculty appointments commensurate with experience Dr. Dan Hunt, Director • Broad range of clinical, academic, and research c/o Danielle Moses, Physician Services experiences Coordinator/Recruiter for Medicine • On-site medical directors Phone: 404-778-7726 • Flexible scheduling options [email protected] • Full malpractice and tail coverage

medicine.emory.edu/hospital-medicine | emoryhealthcare.org/hospital-medicine

Med/Peds Hospitalist KƉƉŽƌƚƵŶŝƟĞƐǀĂŝůĂďůĞ Join the Healthcare Team at Berkshire Health Systems Hospitalist—Charlottesville, VA Berkshire Health Systems is currently seeking BC/BE Med/Peds physicians to join our comprehensive Hospitalist Department Sentara Martha Jefferson Hospital, is • Day and Nocturnist positions currently recruiting for a full time hospitalist • Previous Med/Peds Hospitalist experience is preferred • Leadership opportunities available and nocturnist to join our hospitalist team. Located in Western Massachusetts Berkshire Medical Center is the region’s leading provider of comprehensive health care services Our hospital offers a wide array of patient • Comprehensive care for all newborns and pediatric inpatients including: services, with excellent subspecialty and o Level Ib nursery ancillary support. We strive to create an o 7 bed pediatrics unit environment where safety and quality are o Care for pediatric patients admitted to the hospital • Comprehensive adult medicine service including: the cornerstones to delivering exceptional To advertise in o 302-bed community teaching hospital with residency programs healthcare. We offer competitive salary, o Geographic rounding model benefits, and a cohesive work environment. or the o A closed ICU/CCU The Hospitalist o A full spectrum of Specialties to support the team Journal of Hospital Medicine R$PDMRUWHDFKLQJDI¿OLDWHRIWKH8QLYHUVLW\RI0DVVDFKXVHWWV0HGLFDO *Hospitalist: varied shifts from 8-12 hours School and University of New England College of Osteopathic Medicine • 7 on/7 off 12 hour shift schedule *Nocturnist: 6 nights on/8 off (7p-7a) with We understand the importance of balancing work with a healthy in-house APC cross cover support. personal lifestyle CONTACT: • Located just 2½ hours from Boston and New York City • Small town New England charm Charlottesville is a university town, consistently Heather Gonroski • Excellent public and private schools rated as one of the best places to live, raise 973.290.8259 • World renowned music, art, theater, and museums a family, with excellent schools, metropolitan • Year round recreational activities from skiing to kayaking, this is an ideal [email protected] family location. dining, and outdoor activities. or Berkshire Health Systems offers a competitive Not a J-1/H1-B Visa opportunity. Linda Wilson VDODU\DQGEHQHÀWVSDFNDJHLQFOXGLQJUHORFDWLRQ 973.290.8243 Interested candidates are invited to contact: To apply please submit cover letter and CV to: Liz Mahan, Physician Recruitment Specialist, Berkshire Health Systems [email protected] 725 North St. • Pittsfield, MA 01201 • (413) 395-7866. Paul Tesoriere, M.D. [email protected] Applications accepted online at ZZZEHUNVKLUHKHDOWKV\VWHPVRUJ or call (434) 654-7580 the-hospitalist.org | 29 | January 2019 Make your next smart move. Visit shmcareercenter.org.

Hospitalist Opportunities in Eastern PA – Starting Bonus and Loan Repayment –

We have day positions at our Miners Campus in beautiful Schuylkill County and at our newest hospital in Monroe County set in the Pocono Mountains. Both campuses offer you an opportunity to make a difference in a Rural Health Community yet live in your choice of family friendly, thriving suburban areas. In addition, you’ll have access to our network’s state of the art technology and Network Specialty Support Resources. We also have opportunities at our Quakertown campus, where a replacement hospital will open in 2019.

We offer: • Starting bonus and up to $100,000 in loan repayment • 7 on/7 off schedules • Additional stipend for nights • Attractive base compensation with incentive • Excellent benefits, including malpractice, moving expenses, CME • Moonlighting Opportunities within the Network

SLUHN is a non-profit network comprised of physicians and 10 hospitals, providing care in eastern Pennsylvania and western NJ. We employ more than 800 physician and 200 advanced practitioners. St. Luke’s currently has more than 220 physicians enrolled in internship, residency and fellowship programs and is a regional campus for the Temple/St. Luke’s School of Medicine. Visit www.slhn.org. Our campuses offer easy access to major cities like NYC and Philadelphia. Cost of living is low coupled with minimal congestion; choose among a variety of charming urban, semi-urban and rural communities your family will enjoy calling home. For more information visit www.discoverlehighvalley.com Please email your CV to Drea Rosko at [email protected]

Join a team that empowers you Great Opportunity for a to be a leader in transforming healthcare. Hospitalist in the Southwest Martin Healthcare Group is now San Juan Regional Medical Center in Farmington, NM a part of HNI, creating a new and is recruiting for a hospitalist. This opportunity offers a stronger combined organization great place to live, a caring community and hospital – bolstered by the tradition and environment with a team committed to offering innovation of both a deeply personalized, compassionate care. rooted, mature organization and • 100% Hospitalist work a nimble, technology-enabled one. • Wide variety of critical care • $275,000 base salary + productivity and quality bonus • Excellent Benefits

Interested candidates should contact Terri Smith | [email protected] 888.282.6591 or 505.609.6011 sanjuanregional.com | sjrmcdocs.com

Classified Advertising FIND THE PERFECT FIT! For more information on placing your classified adver- tisement in the next available issue, contact: www.theMHG.com Heather Gonroski • 973.290.8259 Send CV: [email protected] [email protected] or Linda Wilson • 973.290.8243 [email protected]

January 2019 | 30 | The Hospitalist President’s Desk Looking into the future and making history Emergence of population health management

By Nasim Afsar, MD, MBA, front lines of health care delivery. implications of population health SFHM Attendees have the opportunity to management on their clinical topic. hear the two sides and then vote These slides will illustrate the clini- or the first time ever, on on who they believe has the right cal and nonclinical services that are March 7, 2019, tens of thou- approach. There are six precourses necessary to enhance the patient’s sands of hospitalists across planned for HM19, with a new of- quality of care and life. In addition the United States and around fering in Palliative Care and Pain to best practice care, these slides Fthe world will celebrate their day, Management. This year, the annual will highlight topics like the role of National Hospitalist Day. conference also features additional style modification and prevention, On this day, we will honor the sessions for our NP/PA attendees. risk stratification, chronic disease hard work and dedication of hospi- They include specific workshops as management, and care coordination talists in the care of millions of hos- well as a track that includes four throughout the continuum of care. pitalized patients. With more than didactic sessions. Lastly, HM19 will • Advocating for us 62,000 hospitalists across the United offer CME, MOC, AOS, AAFP, and In addition to providing a home for States, hospital medicine has been Pharmacology credits to address the hospitalists to collaborate regarding the fastest growing medical spe- needs of our attendees. population health management, cialty and among the largest of all SHM will advance this agenda from specialties in medicine. Hospitalists A look into the future a regulatory perspective. The Public now lead clinical care in over 75% While hospitalists are a vital part Policy and Performance Measure- of U.S. hospitals, caring for patients of U.S. health care, our delivery sys- ment & Reporting Committees are in their communities. We educate tems are in transition with greater actively evaluating and leading the the future providers of health care focus on value-based care. To en- transition from volume to value. Dr. Afsar is president of the So- by serving as teachers and mentors. sure hospital medicine continues SHM is also working with potential ciety of Hospital Medicine, and We push the boundaries of science to thrive in today’s dynamic scene, key partners and organizations in chief ambulatory officer and chief in hospital care through innova- SHM’s Board of Directors held a the areas of primary care, skilled medical officer for accountable tive research that defines the evi- strategic meeting in October 2018 nursing facilities, and accountable care organizations at UC Irvine dence-based practices for our field. to focus on the role of hospitalists care organizations that will help im- Health. Hospitalists proudly celebrate all and hospital medicine in population prove the effectiveness of delivering that we have accomplished together health management. population health management. on March 7, and moving forward, There are many hospitalists • Creating expertise every first Thursday in March an- across the nation who are current- SHM will lead best practice devel- nually. ly involved in population health opment for tools and skills that are The Society for Hospital Medi- management. These range from necessary for hospitalists to lead Hospitalists now lead cine’s celebration of National Hospi- medical directors to vice presidents population health management. talist Day will include spotlights on of accountable care organizations, Telemedicine is an increasingly “clinical care in over 75% hospitalists, a social medical cam- population health management, or critical tool as we help manage our of U.S. hospitals, caring paign, downloadable customizable value-based care. Hospitalists are patients in other facilities and in posters, and much more. Stay tuned seeking communities focused on inpatient or skilled nursing facili- for patients in their for details! population health management to ties, as well as at home. SHM has communities. We educate share best practices and learn from developed a white paper about tele- The only meeting designed each other. To address this, SHM’s medicine in hospital medicine that the future providers of just for you Advocacy and Public Policy HMX highlights modalities, offerings, im- health care by serving as Be among the thousands of hospi- community has served as a meeting plementation of programs, and work teachers and mentors. talists who will celebrate hospital point to discuss issues related to val- flows necessary for success. You can medicine in person at Hospital ue-based care. To join the discussion, find it under “Resources” at hospital- ” Medicine 2019 (HM19), March 24-27 in visit the community by logging in at medicine.org/telemedicine. National Harbor, Md. hospitalmedicine.org/hmx. Further- SHM will continue to actively While at HM19, check out more more, at HM19, hospitalists will have develop tools that appropriately than 20 educational tracks, includ- the opportunity to meet face to face address the challenges we’re facing. ing clinical updates, diagnostic regarding these issues in the Advo- From National Hospitalist Day to reasoning, and health policy. New cacy Special Interest Forum. population health management, this this year are two mini tracks: “Be- is an exciting time in hospital med- tween the Guidelines” and “Clinical Key points: Population health icine – I hope to see you at HM19 Mastery.” Between the Guidelines management to celebrate our specialty and our explores how we can address some • Source of truth bright future. of the most challenging cases we en- SHM has served as the source of counter in hospital medicine, where reliable and trusted information Correction clear guidelines don’t exist. Clinical about hospital medicine. We will Mastery is designed to enhance our continue to develop content and In the December 2018 Board bedside diagnostic skills, from ECGs resources specific to population Room column, Dr. Christopher to ultrasounds. health management on our website Frost’s employer was identified Get ready to vote in HM19’s “The so hospitalists can easily access incorrectly. Dr. Frost is currently Great Debate” – pairing two talented this information. To increase our national medical director, hospi- clinicians who will debate oppos- awareness about population health tal-based services, at LifePoint ing sides of challenging clinical management, presenters at HM19 Health in Brentwood, Tenn. decisions that we encounter on the will integrate a slide about the the-hospitalist.org | 31 | January 2019 BEATA SUMMER-BRASON, DO HOSPITAL MEDICINE

FEATURED HOSPITAL MEDICINE LEADERSHIP POSITIONS

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