BRIAN HARTE, MD, SFHM NEW: JHM SNEAK PEEK JOHN NELSON, MD, MHM Embrace change as a Highlights from this month’s Effective hospitalist hospitalist leader Journal of Hospital Medicine roles for NPs, PAs PAGE 29 PAGE 11 PAGE 31

VOLUME 21 NO. 1 I JANUARY 2017 AN OFFICIAL PUBLICATION OF THE SOCIETY OF HOSPITAL MEDICINE

PRACTICE MANAGEMENT Ready for What lies ahead? post-acute Uncertainty is the new normal – still, experts say care? hospitalists are primed to help shape American health care. As PAC expands, hospital medicine’s role – and leadership – will be key.

BY KAREN APPOLD

he definition of “hospital- ist,” according to the SHM website, is a clinician “dedi- T cated to delivering compre- hensive medical care to hospitalized patients.” For years, the hospital setting was the specialties’ identifier. But as hospitalists’ scope has expanded, and Graduate School. “There are currently a lot of competing post-acute care (PAC) in the United BY KELLY APRIL TYRRELL ideas floating around and Congress will need to settle on a States has grown, more hospitalists are single approach.” extending their roles into this space. he New Year brings new leadership in the It’s not clear whether Trump will agree with Congress. As a PAC today is more than the tradi- United States, with President-elect Donald J. candidate, he did little to advance policy ideas around health care, tional nursing home, according to Trump taking office later this month. With a though Price’s selection “sends a strong signal that the Trump Manoj K. Mathew, MD, SFHM, Republican-controlled Congress, party leaders administration is serious about undoing the ACA,” Eibner says. national medical director of Agilon T have the opportunity to shape the nation’s poli- “The Republicans now have a hard issue in their hands,” Health in Los Angeles. cies around conservative ideals. This includes health care. says Allison Hoffman, JD, professor of law at UCLA School “Previously, physicians considered Since the Affordable Care Act (ACA) was passed in of Law and an expert on health care law and policy. “It was post-acute care only within the limited 2010, Republicans have vowed to repeal and replace it. hard before the Affordable Care Act, and it will be hard after. scope of what’s This could be their opportunity. There is not an easy solution.” in their own care FIRST OF A However, while policy ideas proposed by House Speaker By 2016, the ACA had expanded health coverage to 20 universe – such TWO-PART Paul Ryan (R-Wis.), and Tom Price – a Republican million people through Medicaid and private insurance on as skilled nursing SERIES House representative, orthopedic surgeon, and Trump’s health care marketplaces. It extended the solvency of the facilities [SNFs], EXAMINING appointed Health & Human Services secretary – could Medicare Hospital Insurance Trust Fund. It accelerated the inpatient reha- POST-ACUTE hold broad Republican appeal, “There is no clear coales- pace of delivery system and payment reform through creation bilitation facili- CARE cence around specific policy reforms that would replace of the Center for Medicare & Medicaid Innovation (CMMI). ties [IRFs], long- the Affordable Care Act,” says Christine Eibner, a senior The law has not been without its challenges. term acute care hospitals [LTACHs], economist at Rand and a professor at the Pardee Rand CONTINUED ON PAGE 18 and home health visits,” Dr. Mathew

Thinkstock says. “But in today’s world, PAC goes well beyond these types of facilities to include other types: postdischarge clin- SHM MEMBER ics, palliative care programs, chronic- Q&A care/high-risk clinics, home care, and SPOTLIGHT telehealth.” Many of those expanded settings Venkataraman Palabindala, Dr. Mathew describes emerged as MD, FHM, leads chapter a result of the Affordable Care Act. development, lends Since its enactment in 2010, the ACA has heightened providers’ focus on expertise to SHM the “Triple Aim” of improving the committees patient experience (including quality

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THE HOSPITALIST HOSPITALIST THE CHANGE SERVICE REQUESTED SERVICE CHANGE CONTINUED ON PAGE 2 PRACTICE MANAGEMENT I CONTINUED FROM PAGE 1

Volume 21 Number 1 January 2017 FRONTLINE MEDICAL COMMUNICATIONS EDITORIAL ADVISORY BOARD Previously, physicians considered SOCIETY PARTNERS Geeta Arora, MD VP/Group Publisher; Director, FMC Society Partners Michael J. Beck, MD post-acute care only within Mark Branca Kevin Conrad, MD, MBA Editor in Chief Mary Jo M. Dales Elizabeth A Cook, MD the limited scope of what’s in their Lisa Courtney, MBA, MSHA Executive Editors Denise Fulton, Kathy Scarbeck Miguel Angel Villagra Diaz, MD Editor Jason Carris Stella Fitzgibbons, MD, FHM own care universe – such as Creative Director Louise A. Koenig Benjamin Frizner, MD, FHM Director, Production/Manufacturing Joshua LaBrin, MD, SFHM skilled nursing facilities, inpatient rehabilitation Rebecca Slebodnik James W. Levy PA-C, SFHM Director, Business Development Angela Labrozzi, David M. Pressel, MD, PhD, FHM facilities, long-term acute-care hospitals, and home 973-206-2971, cell 917-455-6071, Sarah A. Stella, MD [email protected] Amanda T. Trask, MBA, MHA, SFHM Classi‰ ed Sales Representative Jill Waldman, MD, SFHM health visits. David Weidig, MD Heather Gentile, 973-206-8259, Robert Zipper, MD, MMM, SFHM –Manoj K. Mathew, MD, SFHM [email protected] Linda Wilson, 973-290-8243, THE SOCIETY OF HOSPITAL MEDICINE [email protected] Phone: 800-843-3360 Senior Director of Classi‰ ed Sales Tim LaPella, Fax: 267-702-2690 484-921-5001, cell 610-506-3474, Website: www.HospitalMedicine.org Vishal Kuchaculla, MD, New England patients and payors expect. [email protected] Laurence Wellikson, MD, MHM, CEO regional post-acute medical director of “These deficits needed to be quickly Advertising Of‰ ces 7 Century Drive, Suite 302, Parsippany, NJ 07054-4609 Lisa Zoks Boston-based TeamHealth, says new service remedied as patients discharged from hospi- 973-206-3434, fax 973-206-9378 Vice President of Marketing & lines also developed as Medicare clamped tals have increased acuity and higher disease Communications [email protected] down on long-term inpatient hospital stays burdens,” he adds. “Hospitalists were the Physician Editor Brett Radler, Communications Specialist by giving financial impetus to discharge natural choice to fill roles requiring their Danielle B. Scheurer, MD, SFHM, MSCR [email protected] patients as soon as possible. expertise and experience.” [email protected] Felicia Steele, Communications Coordinator “Over the last few years, there’s been a Dr. Muldoon considers the expanded Pediatric Editor [email protected] major shift from fee-for-service to risk- scope of practice into PACs an additional Weijen Chang, MD, FACP, SFHM [email protected] SHM BOARD OF DIRECTORS based payment models,” Dr. Kuchaculla layer to hospital medicine’s value proposi- Coordinating Editors Brian Harte, MD, SFHM says. “The government’s financial incentives tion to the health care system. Christine Donahue, MD President are driving outcomes to improve perfor- “As experts in the management of inpa- THE FUTURE HOSPITALIST Ron Greeno, MD, FCCP, MHM mance initiatives.” tient populations, it’s natural for hospitalists Jonathan Pell, MD President-Elect Another reason for increased Medicare to expand to other facilities with inpatient- KEY CLINICAL GUIDELINES Robert Harrington, Jr, MD, SFHM spending on PAC stems from the fact that like populations,” he says, noting SNFs are Immediate Past President patients no longer need to be hospitalized the most popular choice, with IRFs and CONTRIBUTING WRITERS Nasim Afsar, MD, SFHM Treasurer before going to a PAC setting. LTACHs also being common places to Karen Appold, Alan Briones, MD, FHM, “Today, LTACHs can be used as substi- work. Few hospitalists work in home care Trina Dorrah, MD, MPH, Aymara Fernandez Danielle Scheurer, MD, MSCR, SFHM de la Vara, MD, Jorge Florindez, MD, Alicia Secretary tutes for short-term acute care,” says Sean or hospice. Gallegos, German Giese, MD, Raja Ramesh Tracy Cardin, ACNP-BC, SFHM R. Muldoon, MD, MPH, FCCP, chief PAC settings are designed to help patients Gummalla, MD, Shreevinaya Menon, DO, Howard R. Epstein, MD, SFHM medical officer of Kindred Healthcare in who are transitioning from an inpatient MPH, Jordan Messler, MD, Maria Antonietta Erin Stucky Fisher, MD, MHM Mosetti, MD, M. Alexander Otto, Tierza Christopher Frost, MD, SFHM Louisville, Ky., and former chair of SHM’s setting back to their home or other setting. Stephan, MD, SFHM, Michele G. Sullivan, Jeffrey J. Glasheen, MD, SFHM Post-Acute Care Committee. “This means “Many patients go home after a SNF Kelly April Tyrrell, Sharon Worcester, Jessica Bradley Sharpe, MD, SFHM that a patient can be directly admitted from stay, while others will move to a nursing Zuleta, MD, FHM Patrick Torcson, MD, MMM, SFHM their home to an LTACH. In fact, many home or other longer-term care setting FRONTLINE MEDICAL COMMUNICATIONS hospice and home-care patients are referred for the first time,” says Tiffany Radcliff, Chairman Stephen Stoneburn Vice President, Human Resources & Facility from physicians’ offices without a preceding PhD, a health economist in the depart- President, Digital & CFO Douglas E. Grose Operations Carolyn Caccavelli hospitalization.” ment of health policy and management at President/CEO Alan J. Imhoff Vice President, Marketing & Customer Advocacy President, Custom Solutions JoAnn Wahl Jim McDonough Texas A&M University School of Public Senior Vice President, Finance Steven J. Resnick Vice President, Sales Mike Guire Hospitalists can  ll a need Health in College Station. “With this in Vice President, Society Partners Mark Branca Vice President, Operations Jim Chicca Corporate Director, Research & Communications More hospitalists are working in PACs mind, hospitalists working in PAC have Vice President, Audience Development Donna Sickles Lori Raskin for a number of reasons. Dr. Mathew the opportunity to address each patient’s Vice President, Custom Programs Carol Nathan In affiliation with Global Academy for Medical Education, LLC says that PAC facilities and services have ongoing care needs and prepare them for Vice President, Custom Solutions Wendy Raupers Vice President, Medical Education & Conferences “typically lacked the clinical structure their next setting. Hospitalists can manage Vice President, eBusiness Development Sylvia H. Reitman, MBA Lee Schweizer Vice President, Events David J. Small, MBA and processes to obtain the results that medication or other care regimen changes

THE HOSPITALIST is the official newspaper of the Society THE HOSPITALIST (ISSN 1553-085X) is published monthly of Hospital Medicine and provides the practicing hospitalist for the Society of Hospital Medicine by Frontline Medical with timely and relevant news and commentary about Communications Inc., 7 Century Drive, Suite 302, Parsippany, Medicare claims for 30-day episodes clinical developments and about the impact of health care NJ 07054-4609. Print subscriptions are free for Society of policy on the profession and on surgical practice today. Hospital Medicine members. Annual paid subscriptions are beginning with hospitalization Content for THE HOSPITALIST is provided by Frontline available to all others for the following rates: Medical Communications. Content for the News From the Individual: Domestic – $175 (One Year), $327 (Two Years), College is provided by the Society of Hospital Medicine. $471 (Three Years) Canada/Mexico – $258 (One Year), The ideas and opinions expressed in THE HOSPITALIST do $475 (Two Years), $717 (Three Years) Other Nations- not necessarily reflect those of the College or the Publisher. Surface – $319 (One Year), $615 (Two Years), $901 (Three The Society of Hospital Medicine and Frontline Medical Years) Other Nations-Air – $410 (One Year), $795 (Two Communications will not assume responsibility for damages, Years), $1,204 (Three Years) $21,822 loss, or claims of any kind arising from or related to the Institution: United States – $364; Canada/Mexico – $441 $9,593 information contained in this publication, including any claims All Other Nations – $511 related to the products, drugs, or services mentioned herein. Student/Resident: $51 POSTMASTER: Send changes of address (with old mailing Single Issue: Current – $35 (US), $47 (Canada/Mexico), $7,072 label) to THE HOSPITALIST, Subscription Service, 151 $59 (All Other Nations) Back Issue – $47 (US), $59 $8,727 Fairchild Ave., Suite 2, Plainview, NY 11803-1709. (Canada/Mexico), $71 (All Other Nations) $11,079 To initiate a paid subscription, contact Subscription The Society of Hospitalist Medicine’s headquarters is Services at 1-800-480-4851or [email protected] $6,392 $5,347 located at 1500 Spring Garden, Suite 501, Philadelphia, $3,989 PA 19130. Letters to the Editor: [email protected] DRG 470: Major DRG 065: DRG 194: Simple DRG 690: Kidney Editorial Offices: 2275 Research Blvd, Suite 400, ©Copyright 2017, by Frontline Medical Communications joint replacement Intracranial pneumonia and and urinary tract Rockville, MD 20850, 240-221-2400, fax 240-221-2548 Inc. without MCC1 hemmorage or pleurisy with CC infections without cerebral infarction MCC with CC2 BPA Worldwide is a global industry resource for veri ed audience data and  e Hospitalist is a member.

To learn more about SHM’s relationship with industry partners, visit www.hospitalmedicine.com/industry. Initial acute stay Postdischarge care Advisory Board Source:

2 THE HOSPITALIST I JANUARY 2017 I www.the-hospitalist.org Acute discharge MD, MPH, MBA, FAAFP, SFHM, chair of family medicine at Northwell Health destination in Long Island, N.Y. “This will ultimately The cost of care, and Hospital discharge disposition by prevent unnecessary readmissions.” post-acute care site, patients 65+ Further, the quality metrics that hospitals other PAC facts and figures and thereby hospitalists are judged by no 1.1% longer end at the hospital’s exit. BY KAREN APPOLD acute-care rehabilitation.2 3.3% 11.0% “The ownership of acute-care outcomes It’s also been reported that, after requires extending the accountability to he amount of money that short-term acute-care hospitaliza- outside of the institution’s four walls,” Dr. T Medicare spends on post- tion, about one in five Medicare Mathew says. “The inpatient team needs to acute care (PAC) has been beneficiaries requires continued 17.0% 46.9% place great importance on the transition of increasing. In 2012, 12.6% of specialized treatment in one of care and the subsequent quality of that care Medicare beneficiaries used some the three typical Medicare PAC when the patient is discharged.” form of PAC, costing $62 billion.2 settings: inpatient rehabilitation Robert W. Harrington Jr., MD, SFHM, That amounts to the Centers for facilities (IRFs), LTAC hospitals, 20.7% chief medical officer of Plano, Tex.–based Medicare & Medicaid Services and SNFs.3 Reliant Post-Acute Care Solutions and spending close to 25% of Medicare What’s more, hospital readmis- former SHM president, says the health beneficiary expenses on PAC, a sion nearly doubles the cost of an Home SNF system landscapes are pushing HM beyond 133% increase from 2001 to 2012. episode, so the financial implica- HHA IRF the hospitals’ walls. Among the different types, $30.4 tions for organizations operating LTACH Other “We’re headed down a path that will billion was spent on skilled nurs- in risk-bearing arrangements are Source: DHG Healthcare - 2013 Medicare Standard mandate and incentivize all of us to ing facilities (SNFs), $18.6 billion significant. In 2013, 2,213 hospitals Analytical File (SAF) provide more-coordinated, more-effi- on home health, and $13.1 billion were charged $280 million in read- cient, higher-quality care,” he says. “We on long-term acute care (LTAC) and mission penalties.2 that resulted from an inpatient stay, rein- need to meet patients at the level of care force discharge instructions to the patient that they need and provide continuity and their caregivers, and identify any other through the entire episode of care from issues with continuing care that need to be hospital to home.” addressed before discharge to the next care setting.” How PAC settings differ from hospitals Transitioning care Practicing in PAC has some important Even if a hospitalist is not employed at a nuances that hospitalists from short-term Short-term acute Community PAC, it’s important that they know some- acute care need to get accustomed to, Dr. care hospital thing about them. Muldoon says. Primarily, the diagnostic “As patients are moved downstream capabilities are much more limited, as is Home earlier, hospitalists are being asked to help the presence of high-level staffing. Further, Hospital make a judgment regarding when and patients are less resilient to medication where an inpatient is transitioned,” Dr. changes and interventions, so changes need Assisted Muldoon says. As organizations move to be done gradually. living toward becoming fully risk capable, it is “Hospitalists who try to practice acute- Post-acute care facilities necessary to develop referral networks of care medicine in a PAC setting may become Nursing high-quality PAC providers to achieve the frustrated by the length of time it takes Long-term home best clinical outcomes, reduce readmissions, to do a work-up, get a consultation, and acute care hospital and lower costs.2 respond to a patient’s change of condition,” “Therefore, hospitalists should have a Dr. Muldoon says. “Nonetheless, hospital- working knowledge of the different sites ists can overcome this once recognizing this TOC: Transitions of care of service as well as some opinion on the mind shift.” Inpatient Skilled suitability of available options in their According to Dr. Harrington, another community,” Dr. Muldoon says. “The challenge hospitalists may face is the inabil- rehabilitation nursing hospitalist can also help to educate the ity of the hospital’s and PAC facility’s IT facility facility Source: Society of Hospital Medicine, PACT implementation toolkit hospitalized patient on what to expect at platforms to exchange electronic informa- a PAC.” tion. If a patient is inappropriately prepared for “The major vendors on both sides need the PAC setting, it could lead to incomplete to figure out an interoperability strategy,” highly inefficient process that opens up James D. Tollman, MD, FHM, president management of their condition, which ulti- he says. “Currently, it often takes 1-3 the doors to mistakes and errors of omis- of Boxford, Mass.–based Essex Inpatient mately could lead to readmission. days to receive a new patient’s discharge sion and commission that can result in bad Physicians, believes working in a PAC “When hospitalists know how care is summary. The summary may consist of a patient outcomes.” setting can be a less-demanding environ- provided in a PAC setting, they are better stack of paper that takes significant time to Arif Nazir, MD, CMD, FACP, AGSF, ment for a hospitalist than an inpatient able to ensure a smoother transition of care sort through and requires the PAC facility chief medical officer of Signature Health- facility. “They have much more flexibility between settings,” says Tochi Iroku-Malize, to perform duplicate data entry. It’s a very CARE and president of SHC Medical Part- with their schedule,” he says. “In the hospi- ners, both in Louisville, Ky., cites additional tal, hospitalists have longer, more physi- reasons the lack of seamless communication cally demanding shifts. At SNFs, the level between a hospital and PAC facility is prob- of decision making is often easier; usually lematic. “I see physicians order laboratory they house lower-acuity patients. However, These deficits needed to be quickly tests and investigations that were already there might be more challenges with dispo- done in the hospital because they didn’t sition, family issues, and follow-ups. Plus, remedied as patients discharged from know they were already performed or never you have to do more to coordinate care.” received the results,” he says. “Similarly, I hospitals have increased acuity and see patients continue to take medications What’s ahead? higher disease burdens. Hospitalists prescribed in the hospital long term even Looking to the future, Surafel Tsega, MD, though they were only supposed to take clinical instructor at Mount Sinai Hospital were the natural choice to fill roles requiring their them short term. I’ve also seen patients in New York, says he thinks there will be a come to a PAC setting from a hospital move toward greater collaboration among expertise and experience. without any formal understanding of their inpatient and PAC facilities, particularly –Sean R. Muldoon, MD, MPH, FCCP rehabilitative period and expectations for in the discharge process, given that hospi- recovery.” tals have an added incentive to ensure Despite some frustrations cited by others, CONTINUED ON PAGE 7

www.the-hospitalist.org I JANUARY 2017 I THE HOSPITALIST 3 HOSP_6.indd 1 12/15/2016 8:26:46 PM PRACTICE MANAGEMENT I CONTINUED FROM PAGE 3

Hospitalists working in PAC have the opportunity to address each patient’s ongoing care needs and prepare them for their next setting. Hospitalists can manage medication or other care regimen changes that resulted from an inpatient stay, reinforce discharge instructions to the patient and their caregivers, and identify any other issues with continuing care that need to be addressed before discharge to the next care setting. –Tiffany Radcliff, PhD

CONTINUED FROM PAGE 3 reform will increasingly view an inpatient safe transitions because reimbursement admission as something to be avoided. from the Centers for Medicare & Medic- “If hospitalization can’t be avoided, then aid Services is tied to readmissions and it should be shortened as much as possi- there are penalties for readmission. This ble,” he says. “This will shift inpatient care involves more comprehensive planning into LTACHs, SNFs, and IRFs. Hospitalists regarding “warm handoffs” (e.g., real-time would be wise to follow patients into those discussions with PAC providers about a settings as traditional inpatient census is patient’s hospital course and plan of care reduced. This will take a few years, so hospi- upon discharge), transferring of informa- talists should start now in preparing for that tion, and so forth. downstream transition of individuals who And while it can still be challenging to were previously inpatients.” identify high-risk patients or determine the intensity and duration of their care, Dr. Karen Appold is a freelance medical writer in Mathew says risk-stratification tools and Pennsylvania. care pathways are continually being refined to maximize value with the limited resources References available. In addition, with an increased 1. The role of post-acute care in new care delivery models. American Hospital Association website. Available at http:// emphasis on employing a team approach to www.aha.org/research/reports/tw/15dec-tw-postacute. care, there will be better integration of non- pdf. Accessed Nov. 7, 2016. medical services to address the social deter- 2. Post-acute care integration: Today and in the future. DHG minants of health, which play significant Healthcare website. Available at http://www2.dhgllp. com/res_pubs/HCG-Post-Acute-Care-Integration.pdf. roles in overall health and healing. Accessed Nov. 7, 2016. “Working with community-based organ- 3. Overview: Post-acute care transitions toolkit. Soci- izations for this purpose will be a valuable ety for Hospital Medicine website. Available at http:// www.hospitalmedicine.org/Web/Quality___Innova- tool for any of the population health–based tion/Implementation_Toolkit/pact/Overview_PACT. initiatives,” he says. aspx?hkey=dea3da3c-8620-46db-a00f-89f07f021958. Dr. Muldoon says he believes health care Accessed Nov. 10, 2016.

We’re headed down a path that will mandate and incentivize all of us to provide more-coordinated, more- efficient, higher-quality care. We need to meet patients at the level of care that they need and provide continuity through the entire episode of care from hospital to home. –Robert W. Harrington Jr., MD, SFHM

NEXT MONTH

PART 2 of our series features “8 things post-acute care experts think hospitalists should know.”

www.the-hospitalist.org I JANUARY 2017 I THE HOSPITALIST 7 NEWS I Clinical developments, health care policy, and regulations Infectious disease physicians: Antibiotic shortages are the new norm

BY SHARON WORCESTER were from hospital notification (76%), Frontline Medical News from a colleague (56%), from a pharmacy Of 701 network that contacted them regarding a prescrip- members who AT IDWEEK 2016 tion for the agent (53%), or from the responded to the NEW ORLEANS – Antibiotic shortages Food and Drug Administration website reported by the Emerging Infections or another website on shortages (23%). EIN survey in early Network (EIN) in 2011 persist in 2016, The most common ways of learning 2016, 70% reported according to a web-based follow-up survey about a shortage changed – from notifi- of infectious disease physicians. cation after trying to prescribe a drug in needing to modify Of 701 network members who responded 2011, to proactive hospital/system (local) their antimicrobial to the EIN survey in early 2016, 70% notification in 2016; 71% of respondents choice because reported needing to modify their antimi- said that communications in 2016 were crobial choice because of a shortage in the sufficient. of a shortage in past 2 years. They did so by using broader- Most respondents (83%) reported that the past 2 years. spectrum agents (75% of respondents), more guidelines for dealing with shortages had costly agents (58%), less effective second-line been developed by an antimicrobial stew- —Adi Gundlapalli, MD, PhD

agents (45%), and more toxic agents (37%), ardship program (ASP) at their institution. Thinkstock Adi Gundlapalli, MD, PhD, reported at “This, I think, is one of the highlight an annual scientific meeting on infectious results,” said Dr. Gundlapalli, who is diseases. also a staff physician at the VA Salt Lake cists and programs to help with drug short- Graham, MD, of the Springfield (Ill.) Clinic, In addition, 73% of respondents reported City Health System. “In 2011, we had no age issues. one of the study’s coauthors. “It seems like that the shortages affected patient care or specific question or comments received The overall theme of this follow-up it’s time for the other federal arm – namely, outcomes, reported Dr. Gundlapalli of the about [ASPs], and here in 2016, 83% of survey, in the context of prior surveys in the Food and Drug Administration – to do University of Utah, Salt Lake City. respondents’ institutions had developed 2001 and 2011, is that antibiotic shortages something about this.” The percentage of respondents reporting guidelines related to drug shortages.” are the “new normal – a way of life,” Dr. Dr. Graham said he believes the prob- adverse patient outcomes related to short- Respondents also had the opportunity to Gundlapalli said. lem is in part because of economics, and ages increased from 2011 to 2016 (51% vs. submit free-text responses, and among the “The concerns do persist, and we feel in part because of “the higher standards 73%), he noted at the combined annual themes that emerged was concern regard- there is further work to be done here,” he that the FDA imposes upon these manu- meetings of the Infectious Diseases Soci- ing toxicity and adverse outcomes associ- said. He specifically noted that there is a facturing concerns.” These drugs often are ety of America, the Society of Healthcare ated with increased use of aminoglycosides need to inform and educate fellows and low-profit items, and it isn’t always in the Epidemiology of America, the HIV Medi- because of the shortage of piperacillin-tazo- colleagues in hospitals, increase aware- financial best interest of a pharmaceutical cine Association, and the Pediatric Infec- bactam. Another – described as a blessing in ness generally, improve communication company to upgrade their facilities. tious Diseases Society. disguise – was the shortage of meropenem, strategies, and conduct detailed studies on “But they really have to recognize the The top 10 antimicrobials they reported which led one ASP to “institute restrictions adverse effects and outcomes. importance of having availability of these as being in short supply were piperacillin- on its use, which have continued,” he said. “And now, since ASPs are very pervasive simple agents,” he said, pleading with any tazobactam, ampicillin-sulbactam, mero- “Another theme was ‘simpler agents seem ... maybe it’s time to formalize and deline- FDA representatives in the audience to penem, cefotaxime, cefepime, trimeth- more likely to be in shortage,’ ” Dr. Gund- ate the role of ASPs in antimicrobial short- “maybe think about some of these very high oprim-sulfamethoxazole (TMP-SMX), lapalli said, noting ampicillin-sulbactam in ages,” he said. standards.” doxycycline, imipenem, acyclovir, and 2016 and Pen-G as examples. The problem of antibiotic shortages “hark- Dr. Gundlapalli reported having no disclo- amikacin. TMP-SMX and acyclovir were “And then, of course, the other theme ens back to the day when penicillin was recy- sures. Dr. Graham disclosed relationships in short supply at both time points. across the board ... was our new asset,” he cled in the urine [of soldiers in World War II] with Astellas and Theravance Biopharma. The most common ways respondents said, explaining that some respondents to save this very scarce resource ... but that’s a reported learning about drug shortages commented on the value of ASP pharma- very extreme measure to take,” noted Donald [email protected] Long-term opioid use uncommon among trauma patients

BY MICHELE G. SULLIVAN research fellow at Brigham and Women’s uncommon (9% and 7%, respectively). discontinuation (8% and 11%, respec- Frontline Medical News Hospital, Boston. “Furthermore, we More than half the patients (54%) were tively). There were no significant interac- didn’t find any association of opioid use discharged on an opioid medication. That tions with anxiety or depression. AT THE ACS CLINICAL CONGRESS with depression or anxiety.” percentage dropped very rapidly. By 90 Junior enlisted personnel – the proxy WASHINGTON – Patients with traumatic Dr. Chaudhary examined opioid use days after discharge, group for lower socioeconomic status – injuries don’t appear to be at undue risk among 13,624 patients included in the just 9% of patients and those with a prolonged length of stay of sustained opioid use, a large database Tricare military insurance database. The were still taking the were significantly less likely to get off the review has demonstrated. patients were treated for traumatic injuries drugs. By 1 year, medications, Dr. Chaudhary said. More than half of the 13,000 patients in they received during 2007-2013. Most of only 1% were using “While we strongly believe that these the study were discharged on opioids, but the patients were men (82%), and the larg- opioids. factors should not be used to determine they were able to discontinue them fairly est age group was 18- to 24-year-olds (39%). Dr. Chaudhary who can get opioids, it might make sense rapidly, Muhammad Chaudhary, MD, Military rank was used as a proxy for socio- conducted a multi- to enhance perioperative surveillance said at the annual clinical congress of the economic status in this study: 15% of the variate analysis that and engage pain management services American College of Surgeons. Within 3 cohort had an officer rank, while the rest Dr. Chaudhary controlled for a early on in patients with risk factors, to months, less than one-third were still using were junior or senior enlisted personnel. number of factors, reduce the risk of sustained opioid use,” the drugs, and 1 year later, only 1% were The group was very healthy, with a including age, gender, marital status, he concluded. still taking an opioid pain medication. median Charlson Comorbidity Index rank, mental health status, injury sever- Dr. Chaudhary had no financial disclo- “We found that sustained opioid use score of 0. They were somewhat seriously ity, comorbidities, and treatment envi- sures. was very uncommon among these patients injured, however. The median Injury ronment. Two factors – black race and with moderate-severe traumatic inju- Severity Score was 13, and the range younger age (18-24 years) – significantly [email protected] ries,” said Dr. Chaudhary, a postdoctoral was 9-17. Anxiety and depression were increased the likelihood of early opioid On Twitter @alz_gal

8 THE HOSPITALIST I JANUARY 2017 I www.the-hospitalist.org SOCIETY PAGES I News and information about SHM

Q&A SHM member spotlight Venkataraman Palabindala, MD, FHM, leads chapter development, lends expertise to SHM committees

By Brett Radler SHM, I have become a Fellow in Hospital what we originally set out to do. By creat- Medicine, attended two “Hill Days” to learn ing coupons to encourage membership and Editor’s note: Each month, SHM puts the about the policies, and made a concerted arranging more local meetings using this spotlight on some of our most active members effort to be present at as many meetings as fund, we have been able to experience even who are making substantial contributions to possible, especially SHM’s annual meetings. more success. We are now recognizing that hospital medicine. Visit www.hospitalmedi- The networking, coupled with the work- residents are very excited about SHM meet- cine.org/getinvolved for more information on shops and lectures, is unparalleled. I have ings and are identifying young leaders to be how you can help SHM improve the care of missed only one annual meeting, and I felt part of the hospital medicine movement. hospitalized patients. like I missed a Thanksgiving dinner with my family! Q: How has your participation Question: What inspired you to begin in HMX – and, more broadly, working in hospital medicine and later Q: Can you tell us about your engagement with SHM – helped join – and become so involved with – role in the revitalization of the you improve your practice? SHM? Gulf States Chapter and the A: HMX [connect.hospitalmedicine.org] is ANSWER: I was exploring my options Chapter Development Program? a great platform for asking questions and during my second year of residency at A: During my time as a member of the exchanging ideas. Being active on HMX Dr. Palabindala, FHM, is a Greater Baltimore Medical Center as to SHM Leadership Committee, I quickly has helped me learn important informa- hospitalist at the University of what my final career path should be. I realized that hospitalists in small cities tion about performance metrics, observa- Mississippi Medical Center always loved inpatient medicine, mostly like Dothan, Ala., were not as exposed tion unit models, EHRs, coding and bill- in Jackson. Dr. Palabindala is critical care, so I was thinking of complet- to networking and education activities as ing questions, and sometimes even ethical an active member of SHM’s ing a pulmonary critical-care fellowship. were those in big cities. To unite hospital- questions. IT Committee and has been Completing a hospitalist rotation changed ists in that area of the country, I founded Although I still have mentors helping me, instrumental in growing the Gulf everything about how I saw my future and the Wiregrass Chapter; obtaining 20 signa- I know if I post a question on HMX, that I States Chapter. led me to specialize in hospital medicine. tures to start it was an uphill task. After will get many ideas from hospitalists across Once I learned about SHM and the Dan Dressler, MD, [in Atlanta] and I gave a the nation. I also make it a point to encour- wealth of activities and opportunities talk about updates in hospital medicine, the age friends every month to download the membership offered from a few of my Wiregrass Chapter was awarded the Silver HMX app on their phones and present it attendings, I applied to be part of the Lead- Chapter Award [after its first year in incep- as a valuable resource to my students and ership Committee. I attended every meet- tion], and everything changed. The buzz residents. As hospitalists, this is our forum ing and kept my committee work as a top around the chapter helped it continue to with experts available all the time. priority. At the time, with little experience grow. To encourage others to use the platform and make myself and fellow committee members accessible to other members, we actively take turns assuming responsibility for maintaining the momentum on HMX Now that hospitalists have left their stamp on inpatient by finding intriguing topics of discussion.

medicine, specialties like critical care, nephrology, car- Q: As we ring in 2017 after a year of many changes for HM and the diology, and ob.gyn. are moving toward this model. We health care system in general, need to do everything we can to integrate them into our what do you see as the biggest HM opportunities this year? pool, move forward together, and learn from each other. A: We know physician retention and burn- out are some of the biggest challenges in hospital medicine. Given the pace at which we are growing as a specialty, I would like to see more time dedicated to addressing and in hospital medicine, I knew I might not After I moved to Jackson, I applied for attempting to alleviate these specific issues. have as much to contribute as the rest, but a pilot funding project to start a Jackson Also, now that hospitalists have left their my goal was to learn as much as I could. Chapter, as I realized the Gulf States Chap- stamp on inpatient medicine, specialties like Never once did I feel that my voice was any ter was a bit far away. I thought a local chap- critical care, nephrology, cardiology, and more or less valuable than those of the rest ter would bring all hospitalists in this area ob.gyn. are moving toward this model. We of the committee members; our committee together. However, I received a call from need to do everything we can to integrate work was truly a collaborative effort. Lisa Chester, our chapter liaison at SHM, them into our pool, move forward together, As my career in hospital medicine has about being a part of the Gulf States Chap- and learn from each other. evolved, so have my contributions to SHM’s ter and serving as a catalyst to revitalize the Lastly, mentorship is of paramount committees; I now am a proud member of chapter. importance as we head into the future. the IT Committee. We’re currently work- I was thrilled to work with Randy Roth, We must encourage young hospitalists to ing on a white paper about hospitalists’ MD, and Steven Deitelzweig, MD; both are mentor students and residents and recruit attitudes toward electronic health record hospitalist leaders in this area. The Chap- them to be part of SHM when they return (EHR) systems and look forward to shar- ter Development Program surely helped home. ing more about that next month. us to create new goals and develop a realis- In addition, throughout my time with tic timeline. It kept us on track to achieve Brett Radler is SHM’s communications specialist.

www.the-hospitalist.org I JANUARY 2017 I THE HOSPITALIST 9 SOCIETY PAGES I News and information about SHM Sneak Peek: The Hospital Leader blog SNEAK PEEK Post election, what will change about how I treat at the bedside? Nothing.

BY JORDAN MESSLER, MD, became fatigued and swollen. She came to suggested it was benign. We allowed a smile, lift our heads up and know we will fight for SFHM the ER after weeks of suffering with what but final tests were pending. What will turn another day, and another day, and not stop turned out to be failing kidneys. Lupus. up? When the final results return? Can we fighting until the cancer upon us is gone? To my next patient: She required expensive medications that dance in the room with joy? Or will we hold would aim to reverse her kidney disease. hands, bear the cross, shed a tear, but then Read the full post at www.hospitalleader.org. I often avoid putting my politics on my She left the hospital not knowing what sleeve, as I don’t want that to get in the would happen next, as there was no way way of our relationship. I want you to she could afford the treatment. The fates of know that I treat you as a fellow human medicine handed her an unexpected illness, ALSO ON “THE HOSPITAL being, no matter your race, gender, sexual and we had no good way to reassure her LEADER” BLOG orientation. With the election results, what of what would come next. I am sorry that will change about how I treat you at the more patients without insurance will arrive, bedside? Nothing. instead of the steady decline I had been used POST: An open letter to hospital executives about their hospitalist I may know about your criminal past. to the past few years. programs I see that tattoo underneath your gown. I You also remind me of another patient By Leslie Flores, MHA, SFHM hear your profanity-filled screed because I saw last week. She was sweet in the face, you won’t get that MRI today. I know you smiling despite her travails, and wore the POST: What’s under the hood? A quick look at hospital expenses don’t follow the treatment plan, that you are skimpy gown with pride. She had some By Brad Flansbaum, DO, MPH, MHM here illegally, or that you are a refugee from fluid just outside her lung that shouldn’t be another country. there: a pleural effusion. We discussed the POST: A quick lesson on bundled payments I will still care for you no matter what. It’s different possible diagnoses. She had cancer By John Nelson, MD, MHM one of the blessed things we instill in each in the past, surgically treated and presum- other in medicine. ably cured. Was this the cancer back? Was POST: The ABIM Has new plans for MOC and wants your opinion. Give it I saw someone like you recently: 28 years it an infection, easily treated? We couldn’t to ’em! old, working hard, with two jobs, neither of tell by the exam or the x-ray. By Burke Kealey, MD, SFHM which provided insurance. She was doing On Tuesday, we took the fluid out. The well, without health problems, but then she results trickled in slowly, and initial tests

NEWS & NOTES

Develop curricula to your experiences with inpatient elec- vention units. Trending at educate, engage medical tronic health record (EHR) systems. • Starting to design and implement students and residents The results will serve as a foundation key interventions. SHM hThe ACGME requirements for for a white paper to be written by the Even if you’re not in this mentored training in quality and safety are HIT Committee addressing hospital- implementation cohort, visit www. The latest news, events, changing – it is no longer an elective. ists’ attitudes toward EHR systems. hospitalmedicine.org/RADEO and programs, and SHM initiatives. As sponsoring institutions’ residen- It will be released next month, so stay view the online toolkit or download cy and fellowship programs mobilize tuned then to view the final paper. the implementation guide. By Brett Radler to meet these requirements, leaders may find few faculty members are SHM chapters: Your connection Earn recognition for your Unveiling the hospitalist comfortable enough with the mate- to local education, networking, research with SHM’s Junior specialty code rial to teach and create educational leadership opportunities Investigator Award hThe Centers for Medicare & content for trainees. These faculty hSHM offers various opportunities hThe SHM Junior Investigator Award Medicaid Services announced in need further development. to grow professionally, expand your was created for junior/early-stage November the official implementa- Sponsored by SHM, the Quality and CV, and engage with other hospital- investigators, defined as faculty in the tion date for the Medicare physi- Safety Educators Academy (QSEA) ists. With more than 50 chapters first 5 years of their most recent posi- cian specialty code for hospitalists. responds to that demand by providing across the country, you can network, tion/appointment. Applicants must be On April 3, “hospitalist” will be an medical educators with the knowl- learn, teach, and continue to improve a hospitalist or clinician-investigators official specialty designation under edge and tools to integrate quality patient care at a local level. Find a whose research interests focus on Medicare; the code will be C6. improvement and safety concepts chapter in your area or start a chapter the care of hospitalized patients, the Starting on that date, hospitalists into their curricula. The 2017 meeting today by visiting www.hospitalmedi- organization of hospitals, or the prac- can change their specialty desig- is Feb. 26-28 at the Tempe Mission cine.org/chapters. tice of hospitalists. Applicants must nation on the Medicare enrollment Palms Hotel in Arizona. This 2½ day be members of SHM in good stand- application (Form CMS-855I) or meeting aims to fill the current gaps Enhance opioid safety ing. Nominations from mentors and through CMS’ online portal (Provider for faculty by offering basic concepts for inpatients self-nominations are both welcome. Enrollment, Chain, and Ownership and educational tools in quality hSHM enrolled 10 hospitals into a The winner will be invited to System, or PECOS). improvement and patient safety. second mentored implementation receive the award during SHM’s Appropriate use of specialty Material is presented in an interactive cohort around Reducing Adverse annual meeting, HM17, May 1-4, at codes helps distinguish differences way, providing guidance on career Drug Events Related to Opioids Mandalay Bay Resort and Casino in among providers and improves and curriculum development and (RADEO). The program is now in Las Vegas. The winner will receive the quality of utilization data. SHM establishing a national network of its second month as the sites work complimentary registration for this applied for a specialty code for quality and safety educators. with their mentors to enhance safety meeting as well as a complimentary hospitalists nearly 3 years ago, and For more information and to regis- for patients in the hospital who are 1-year membership to SHM. CMS approved the application in ter, visit www.shmqsea.org. prescribed opioid medications by: For more information on the appli- February 2016. • Developing a needs assessment. cation process, visit www.hospital- Stand with your fellow hospital- EHRs: blessing or curse? • Putting in place formal selections medicine.org/juniorinvestigator. ists and make sure to declare, “I’m hSHM’s Health Information Technol- of data collection measures. a C6.” ogy (HIT) Committee invited you to • Beginning to take outcomes and Brett Radler is SHM’s communications participate in a brief survey to inform process data collection on inter- specialist.

10 THE HOSPITALIST I JANUARY 2017 I www.the-hospitalist.org Sneak Peek: Journal of Hospital Medicine SNEAK PEEK Discharges against medical advice at a county hospital: Provider perceptions and practice

By Cordelia R. Stearns, MD, DESIGN: This mixed-methods cross- CONCLUSIONS: Although provid- A longitudinal qualitative Allison Bakamjian, BA, Subrina sectional study involved chart abstrac- ers overall felt comfortable determin- study of complex patients Sattar, MD, Miranda Ritterman tion and survey administration. ing capacity and discussing AMA Authors: Soo Chan Carusone, PhD, Weintraub, PhD, MPH discharges, they rarely documented Bill O’Leary, MSW, Simone McWatt, PARTICIPANTS: Charts were these discussions. Nurses and MPH, Ann Stewart, MSc, MD, Shelley reviewed for all AMA discharges (n physicians differed in their thinking Craig, MSW, PhD, David J. Brennan, FEATURED = 319) at a county hospital in 2014. regarding whether to arrange follow- MSW, PhD Surveys were completed by 178 up for patients leaving AMA, and in ABSTRACT health care providers at the hospital. practice, arrangements were seldom Do clinicians understand made. quality metric data? An BACKGROUND: Patients RESULTS: Of 12,036 admissions, Read the full article at journalof evaluation in a Twitter- discharged against medical advice 319 (2.7%) ended with an AMA hospitalmedicine.com. derived sample (AMA) have higher rates of read- discharge. Compared with conven- Authors: Sushant Govindan, MD, mission and mortality than patients tionally discharged patients, patients Also in the January 2017 issue of Vineet Chopra, MD, MSc, Theodore J. who are conventionally discharged. who left AMA were more likely to be JHM… Iwashyna, MD, PhD Bioethicists have proposed best young, male, and homeless and less practice approaches for AMA likely to be Spanish speaking. Of the Characteristics and outcomes Routine replacement of discharges, but studies have AMA patients, 29.6% had capacity of fasting orders among peripheral intravenous revealed that some providers have documented, 21.4% had medications medical inpatients catheters misconceptions about their roles in prescribed, and 25.7% had follow- Authors: Atsushi Sorita, MD, MPH, Authors: Sanjay A. Patel, MD, Michael these discharges. up arranged. Of patients readmitted Charat Thongprayoon, MD, John T. M. Alebich, DO, Leonard S. Feldman, within 6 months after AMA, 23.5% left Ratelle, MD, Ruth E. Bates, MD, Katie MD OBJECTIVE: This study assessed AMA again at the next visit. Attend- M. Rieck, MD, Aditya P. Devalapa- patient characteristics and provider ing physicians and trainee physicians lli, MD, Adil Ahmed, MD, Deanne T. Physicians are often practices for AMA discharges at a were more likely than nurses to say Kashiwagi, MD incorrect about the telemetry county hospital and provider percep- that AMA patients should receive status of their patients tions and knowledge about AMA medications and follow-up (94% and The lived experience of the Authors: Sajan Patel, MD, Sayumi De discharges. 84% vs. 64%; P less than .05). hospital discharge “plan”: Silva, MD, Erin Dowling, MD

www.the-hospitalist.org I JANUARY 2017 I THE HOSPITALIST 11 EVERYTHING WE SAY AND DO I Communication Tactics from SHM’s Patient Experience Committee Read the chart Elevate your patients’ confidence

By Trina Dorrah, MD, MPH

Editor’s note: “Everything We Say and Do” is an informational series developed by SHM’s Patient Experience Committee to provide readers with thoughtful and action- able communication tactics that have great It does not matter potential to positively impact patients’ expe- rience of care. Each article will focus on how which technique you the contributor applies one or more of the “key communication” tactics in practice to use. It simply matters maintain provider accountability for “every- thing we say and do that affects our patients’ that you take time to thoughts, feelings, and well-being.” review your patient’s What I say and do chart prior to entering I inform my patients that I have reviewed their chart and that I am familiar with their the room and that diagnosis.

you verbalize what Why I do it In the hospital setting, in particular, patients you have learned. In are concerned about communication between their various health care profes- patients, this inspires sionals. Many times, the patient’s primary- confidence and trust care provider works strictly in the outpatient setting, so the hospitalist is the person who and helps alleviate assumes total care of the patient throughout hospitalization. This understandably creates concerns that the anxiety for patients and families because they wonder if the hospitalist really knows physician does not their medical history. One way to alleviate this anxiety is to review your patients’ charts it is only the first step. The next step is to place in your clinic note. That way, prior to know important prior to speaking with them and to verbally let my patient and family know that I have seeing the patient, you can always review let your patients know you are familiar with read the chart and that I am up-to-date your last note and know the important information in their their diagnoses. on my patient’s diagnosis. I feel it is very information about your patient’s medical medical history. important for me to verbalize that I have history will always be in the same place in How I do it read the chart because without doing this, each note. Another tip is to use your EHR’s Before entering the room, my patients never really know that I took note function. My EHR has “sticky notes,” STEP 1: I review my patient’s the time prior to entering the room to learn and they provide a place for the PCP to chart. If I am taking over the service from about them. store information about the patient without my colleague, I review all notes from the I might say: it becoming part of the permanent medical current hospitalization to ensure I under- • “I was reviewing your chart before I came record. stand everything that has happened. I also in, and I saw that your daughter brought These notes allow the PCP to record review tests, procedures, and radiographic you to the hospital for chest pain.” important events that happen between one studies. To gain a better understanding of • “I read your chart and saw that you have clinic visit and the next. Thus, when the my patient, I read the most recent discharge been to the emergency room twice in the patient returns to the clinic, the PCP opens summary and outpatient clinic note. Like- last week.” the chart, reviews the sticky note, and enters wise, if I am admitting a new patient to • “I read your primary-care doctor’s note, the exam room prepared to discuss signifi- the hospital, before entering the room to and I saw that she recently treated you for cant events in the patient’s recent medical do the history and physical examination, I pneumonia.” history. review recent hospitalizations, clinic notes, • “I read your chart, and I wanted to In the end, it does not matter which tech- and emergency department visits. confirm a few things I read to ensure we nique you use. It simply matters that you I also like to review the chart to see if are on the same page.” take time to review your patient’s chart prior I have taken care of the patient before. There are many different ways you can to entering the room and that you verbal- Patients often remember me even though I phrase this, but the important point is to ize what you have learned. In patients, this may not remember them, so reviewing my make sure your patients know you read the inspires confidence and trust and helps prior notes may be helpful. Thankfully, my chart by specifically referencing something alleviate concerns that the physician does electronic health record (EHR) has a search you learned. This helps your patients feel not know important information in their function where I can enter my name or any more confident that you know their medi- medical history. other keyword and it searches for patient cal history. records based on this keyword. I know some of the doctors reading Dr. Dorrah is regional medical director for this column see patients in the outpatient quality and the patient experience at Baylor Even though reading setting. One way to help yourself remem- Scott & White Health in Round Rock, Tex. She STEP 2: the chart and being ber pertinent facts about a patient’s medical is a member of SHM’s Patient Experience informed about my patient is important, history is to include these facts in a specific Committee.

CHECK OUT KEY COMMUNICATION TACTICS HIGHLIGHTED IN “Everything We Say and Do” at the-hospitalist.org.

12 THE HOSPITALIST I JANUARY 2017 I www.the-hospitalist.org CLINICAL

IN THE LITERATURE ITL: Physician reviews of HM-centric research By Jorge Florindez, MD; German Giese, MD; Raja Ramesh Gummalla, MD; Jessica Zuleta, MD, FHM; Maria Antonietta Mosetti, MD; Shreevinaya Menon, DO, MPH; Aymara Fernandez de la Vara, MD; and Alan Briones, MD, FHM University of Miami Health System

IN THIS ISSUE ers across all specialties. LEJR is the most omized to either receive an ICD or usual common Medicare inpatient procedure, clinical care. The primary outcome, death costing more than $6 billion in 2014. from any cause, occurred in 120 patients 1 Physicians and EHR time, p. 13 STUDY DESIGN: Observational study. (21.6%) in the ICD group (4.4 events/100 SETTING: BPCI-participating hospitals. person-years) and in 131 patients (23.4%) 2 Bundled payments reduce costs in joint patients, p. 13 SYNOPSIS: At BPCI-participating hospitals, in the control group. The hazard ratio for 3 Nonischemic cardiomyopathy does not benefit from prophylactic ICDs, p. 13 there were 29,441 LEJR episodes in the death from any cause in the ICD group, as baseline period and 31,700 episodes in the compared with the control group, was 0.87 4 Pulmonary embolism in COPD exacerbations, p. 13 intervention period; these were compared (95% CI , 0.68-1.12; P = .28). The HR for 5 Evaluating the qSOFA, p. 14 with a control group of 29,440 episodes in death from any cause in the ICD group, as the baseline period and 31,696 episodes in compared with the control group, was 0.87 6 Inpatient antibiotic use has not declined, p. 14 the intervention period. The BPCI initiative (95% CI, 0.68-1.12; P = .28) BOTTOM LINE: 7 Instability of INRs, p. 14 was associated with a significant reduction Prophylactic ICD implanta- in Medicare per-episode payments, which tion in patients with symptomatic NISHF 8 Blood thinning with bioprosthetic valves, p. 14 declined by an estimated $1,166 more (95% does not reduce long-term mortality. confidence interval, –$1634 to –$699; P less CITATION: Kober L, Thune JJ, Nielsen JC, 9 Inhalers used incorrectly at least one-third of time, p. 14 than .001) for the BPCI group than for the et al. Defibrillator implantation in patients 10 Updated recommendations for managing gout, p. 15 comparison group (between baseline and with nonischemic systolic heart failure. N intervention periods). Engl J Med. 2016;375:1221-1230. 11 Home treatment of PE remains rare, p. 15 There were no statistical differences in 12 Non–vitamin K antagonist oral anticoagulants for planned atrial fibrillation claims-based quality measures between Pulmonary embolism in COPD cardioversions, p. 15 the BPCI and comparison populations, 4exacerbations which included 30- and 90-day unplanned CLINICAL QUESTION: How frequent is pulmo- 13 Fecal transplant efficacy for Clostridium difficile infections, p. 15 readmissions, ED visits, and postdischarge nary embolism (PE) in patients with unex- 14 Overnight extubations associated with worse outcomes, p. 15 mortality. plained acute chronic obstructive pulmo- BOTTOM LINE: Bundled payments for joint nary disease (COPD) exacerbation? 15 Vent bundles and ventilator-associated pneumonia outcomes, p. 15 replacements may have the potential to BACKGROUND: Acute COPD exacerbations decrease cost while maintaining quality of are highly inflammatory states, and since 16 Do not overtreat febrile neutropenia, p. 16 care. there is a well-known interaction between 17 What to do with isolated calf DVT, p. 16 CITATION: Dummit L, Kahvecioglu D, inflammatory pathways and thrombosis, Marrufo G, et al. Association between PE occurs with increased prevalence, rang- hospital participation in a Medicare ing from 18% to 25%. In approximately bundled payment initiative and payments 30% of cases of acute exacerbations of and quality outcomes for lower extrem- COPD, no clear etiology is found. By Alan Briones, MD, FHM reported diaries showed an additional 1-2 ity joint e replacement episodes. JAMA. STUDY DESIGN: Systematic review. hours of follow-up work on the EHR. 2016;316(12):1267-1278. SETTING: U.S. hospitals and EDs. Physicians and EHR time These observations might not be general- SYNOPSIS: PE prevalence was 16.1% (95% 1CLINICAL QUESTION: How much time do izable to other practices. No formal statis- Dr. Briones is an assistant professor at the CI, 8.3%-25.8%) in patients with unex- ambulatory-care physicians spend on elec- tical comparisons by physicians, practice, University of Miami Miller School of Medi- plained COPD exacerbations. Thirty-two tronic health records (EHRs)? or EHR characteristics were done. cine and medical director of the hospitalist percent were subsegmental, 35% affected BACKGROUND: There is growing concern BOTTOM LINE: Ambulatory-care physicians service at the University of Miami Hospital. one of the main pulmonary arteries, and about physicians’ increased time and effort appear to spend more time with EHR 32% were located in the lobar and inter- allocated to the EHR and decreased clini- tasks and desk work than clinical face By German Giese, MD lobar arteries. Heterogeneity between the cal face time and meaningful interaction time with patients. included studies was high. In-hospital and with patients. Prior studies have shown that CITATION: Sinsky C, Colligan L, Li L, et al. Nonischemic cardiomyopathy does 1-year mortality were increased in patients increased physician EHR task load is asso- Allocation of physician time in ambula- 3not bene t from prophylactic ICDs with PE and COPD exacerbations in one ciated with increased physician stress and tory practice: a time and motion studies CLINICAL QUESTION: Do prophylactic study but not in another. dissatisfaction. in 4 specialties [published online ahead implantable cardioverter defibrillators Signs of cardiac failure, hypotension, STUDY DESIGN: Time and motion observa- of print Sept. 6, 2016]. Ann Intern Med. (ICDs) reduce long-term mortality in and syncope were more frequently found tion study. 165(11):753-760. patients with symptomatic nonischemic in patients with COPD exacerbation and SETTING: Ambulatory-care practices. systolic heart failure (NISHF)? PE, compared with patients with COPD SYNOPSIS: Fifty-seven physicians from Bundled payments reduce costs BACKGROUND: ICDs are associated with exacerbation without PE. 16 practices in four U.S. states partici- 2 in joint patients significant reductions in the rate of sudden BOTTOM LINE: PE is a common occurrence pated and were observed for more than CLINICAL QUESTION: Does bundled payment cardiac death and mortality in NISHF in patients with unexplained COPD exac- 430 office hours. Additionally, 21 physi- for lower extremity joint replacement patients. However, no trials of NISHF erbations; two-thirds of those emboli cians completed a self-reported after- (LEJR) reduce cost without compromis- patients have shown an effect on total involved segmental circulation and there- hours diary. During office hours, physi- ing the quality of care? mortality. fore were clinically relevant. cians spent 49.2% of their total time on BACKGROUND: Conventionally, Medicare STUDY DESIGN: Multicenter, nonblinded, CITATION: Aleva FE, Voets LW, Simons SO, the EHR and desk work and only 27% makes separate payments to provid- randomized controlled prospective trial. de Mast Q, van der Ven A, Heijdra YF. on face time with patients. While in the ers for the individual services rendered SETTING: Danish ICD centers. Prevalence and localization of pulmonary exam room, physicians spent 52.9% of to patients. The Bundled Payments for SYNOPSIS: A total of 1,116 patients with embolism in unexplained acute exacerba- the time on direct clinical face time and Care Improvement (BPCI) program was symptomatic NISHF (left ventricular ejec- tions of COPD: a systematic review and 37% on the EHR and desk work. Self- developed to align incentives for provid- tion fraction of less than 35%) were rand- CONTINUED ON PAGE 14

www.the-hospitalist.org I JANUARY 2017 I THE HOSPITALIST 13 IN THE LITERATURE I continued from page 13

meta-analysis [published online ahead of apy/1,000 patient-days increase; 95% CI, BACKGROUND: The main advantage of print Aug. 11, 2016]. Chest. doi: 10.1016/j. –18.9 to 30.1; P = .65) was not statisti- bioprosthetic valves, compared with chest.2016.07.034. cally significant. There was a significant mechanical valves, is the avoidance of decrease in the use of aminoglycosides, long-term anticoagulation. Current Dr. Giese is an assistant professor at first- and second-generation cephalo- guidelines recommend the use of vita- the University of Miami Miller School sporins, fluoroquinolones, sulfonamide, min K antagonist (VKA) during the of Medicine and a hospitalist at the metronidazole, and penicillins. The use first 3 months after surgery, which University of Miami Hospital and Jackson of third- and fourth-generation cephalo- remains controversial. Two randomized Memorial Hospital. sporins, macrolides, glycopeptides, beta- controlled trials (RCTs) showed no bene- lactam/beta-lactamase inhibitor, carbap- fit of using VKA in the first 3 months; By Shreevinaya Menon, DO, MPH enems, and tetracyclines has increased however, other studies have reported significantly. conflicting results. Evaluating the qSOFA Limitations of the study include under- STUDY DESIGN: Meta-analysis and systematic 5CLINICAL QUESTION: How does the quick representation of pediatric hospitals and review. Sepsis-Related Organ Failure Assessment certain geographic regions. SETTING: Multicenter. (qSOFA) compare with other sepsis scor- BOTTOM LINE: Antibiotic-use rates have not SYNOPSIS: This meta-analysis included two ing tools? changed during 2006-2012. However, RCTs and 12 observational studies that BACKGROUND: The qSOFA score has been broad-spectrum antibiotic use has increased compared the outcomes in group I (VKA) shown to be superior to the Sepsis-Related significantly. versus group II (antiplatelet therapy/no Organ Failure Assessment (SOFA) with CITATION: Baggs J, Fridkin SK, Pollack LA, treatment). There was no difference in respect to predicting in-hospital mortal- Srinivasan A, Jernigan JA. Estimating national thromboembolic events between group I ity outside of the ICU. It has not been trends in inpatient antibiotic use among US (1%) and group II (1.5%), but there were compared to other scoring systems or tested hospitals from 2006 to 2012. JAMA Intern more bleeding events in group I (2.6%) among ED patients. Med. 2016;176(11):1639-1648. versus group II (1.1%). In addition, no STUDY DESIGN: Single-center, retrospective differences in all-cause of mortality rate and analysis. Dr. Menon is an assistant professor at the need for redo surgery were found between SETTING: Hospital ED in China. University of Miami Miller School of Medi- the two groups. SYNOPSIS: A total of 516 adult ED cine and a hospitalist at University of Miami BOTTOM LINE: The use of VKA in the first 3 patients with clinically diagnosed infec- Hospital and Jackson Memorial Hospital. months after a bioprosthetic valve implan- tions were followed for 28 days. Calcu- tation does not decrease the rate of throm- lated scores for qSOFA, SOFA, Mortal- By Jorge Florindez, MD boembolic events or mortality, but it is ity in ED Sepsis (MEDS), and Acute associated with increased risk of major Physiology and Chronic Health Evalua- Instability of INRs bleeding. tion (APACHE) II were compared using 7 CLINICAL QUESTION: Does an initial stable CITATION: Masri A, Gillinov M, John- ROC curves. international normalized ratio (INR) ston DM, et al. Anticoagulation versus qSOFA was similar to the other scoring predict long-term stability? antiplatelet or no therapy in patients systems to predict ICU admission. BACKGROUND: Warfarin decreases stroke undergoing bioprosthetic valve implan- The area under the curve for qSOFA to risk among patients with atrial fibrilla- tation: a systematic review and meta- predict 28-day mortality was lower than tion; however, it interacts with food and analysis [published online ahead of print all other scoring systems but was statisti- drugs and requires monitoring to achieve Aug. 3, 2016]. Heart. doi: 10.1136/ cally significant only when compared to a therapeutic INR. It is unclear if patients heartjnl-2016-309630. MEDS. A qSOFA score of 2 had a posi - on warfarin with an initial stable INR value tive likelihood ratio of 2.47 to predict remain stable over time. Additionally, it is Inhalers used incorrectly at least mortality (95% CI, 2.3-5.4) and a posi- controversial whether patients on warfarin 9one-third of time tive likelihood ratio of 2.08 (95% CI, with previously stable INRs should benefit CLINICAL QUESTION: What are the most 1.7-4.1) to predict ICU admission. from switching to a non–vitamin K oral common errors in inhaler use over the past BOTTOM LINE: qSOFA was similar to anticoagulant. 40 years? other scoring systems to predict 28-day STUDY DESIGN: Retrospective study. BACKGROUND: One of the reasons for poor mortality and ICU admission but SETTING: Outpatient clinics. asthma and COPD control is incorrect slightly inferior than MEDS to predict SYNOPSIS: Data were collected from the inhaler use. Problems with technique mortality. Outcomes Registry for Better Informed have been recognized since the launch of CITATION: Wang JY, Chen YX, Guo SB, Mei Treatment of Atrial Fibrillation. Included the metered-dose inhaler (MDI) in the X, Yang P. Predictive performance of quick in the study were patients taking warfarin 1960s. Multiple initiatives have been sepsis-related organ failure assessment for at baseline with three or more INR values implemented, including the design of mortality and ICU admission in patients in the first 6 months and six or more INR the dry powder inhaler (DPI); however, with infection at the ED. Am J Em Med. values in the subsequent year. Stability was problems persist despite all corrective 2016;34(9):1788-1793. defined as 80% or more INRs in therapeu- measures. tic range (2.0-3.0). STUDY DESIGN: Meta-analysis. Inpatient antibiotic use has not Only 26% of patients taking warfarin had SETTING: Multicenter. 6declined a stable INR during the first 6 months, and SYNOPSIS: The most frequent MDI errors CLINICAL QUESTION: How has inpatient anti- only 34% continued to have a stable INR were lack of initial full expiration (48%), biotic use changed in the United States in in the subsequent year. inadequate coordination (45%), and no recent years? BOTTOM LINE: Initial stable INR within postinhalation breath hold (46%). DPI BACKGROUND: Antibiotic resistance is a the first 6 months among patients taking errors were lower, compared with MDI result of inappropriate antibiotic use. warfarin does not predict long-term INR errors: incorrect preparation (29%), no Understanding antibiotic trends will help stability in the subsequent year. initial full expiration before inhalation improve antibiotic stewardship efforts. CITATION: Pokorney SD, Simon DN, (46%), and no postinhalation breath hold STUDY DESIGN: Retrospective analysis. Thomas L, et al. Stability of interna- (37%). SETTING: Adult and pediatric data from 300 tional normalized ratios in patients taking The overall prevalence of correct tech- acute-care hospitals, 2006-2012. long-term warfarin therapy. JAMA. nique was the same as poor technique SYNOPSIS: Weighted extrapolation of 2016;316(6):661-663. (31%). There was no difference in the rates data from a database was used to esti- of incorrect inhaler use between the first mate national antibiotic use. Overall, Blood thinning with bioprosthetic and second 20-year periods of investigation. 55.1% of discharged patients received 8valves BOTTOM LINE: Incorrect inhaler use in antibiotics. The rate of antibiotic use CLINICAL QUESTION: Does anticoagulation patients with asthma and COPD persists was 755/1,000 patient-days over the prevent thromboembolic events in patients over time despite multiple implemented study period. The small increase in anti- undergoing bioprosthetic valve implanta- strategies. biotic use over the years (5.6 days of ther- tion? CITATION: Sanchis J, Gich I, Pedersen S,

14 THE HOSPITALIST I JANUARY 2017 I www.the-hospitalist.org Aerosol Drug Management Improvement of patients (1.7%) were eligible for outpa- to enoxaparin-warfarin therapy. with higher mortality rate? Team. Systematic review of errors in inhaler tient therapy, and an additional 16.2% of CITATION: Goette A, Merino JL, Ezekowitz BACKGROUND: Little is known about the use: has the patient technique improved hospitalized patients were discharged early MD, et al. Edoxaban versus enoxaparin- frequency, safety, and effectiveness of over- over time? Chest. 2016;150(2):394-406. (2 days or less). Novel oral anticoagulants warfarin in patients undergoing cardio- night extubations in the ICU. were administered to fewer than one-third version of atrial fibrillation (ENSURE- STUDY DESIGN: Retrospective cohort study. Dr. Florindez is an assistant professor at the of patients. AF): a randomised, open-label, phase 3b SETTING: One-hundred sixty-five ICUs in University of Miami Miller School of Medi- BOTTOM LINE: In the era of novel anticoagu- trial. Lancet. 2016;388(10055):1995- the United States. cine and a hospitalist at University of Miami lants, the majority of patients with acute 2003. SYNOPSIS: Using the Project IMPACT data- Hospital and Jackson Memorial Hospital. PE were hospitalized, and home treatment base, 97,844 adults undergoing mechani- was infrequently selected for stable low-risk Fecal transplant ef cacy for cal ventilation (MV) admitted to ICUs By Raja Ramesh Gummalla, MD patients. 13Clostridium dif cile infections were studied. Overnight extubation was CITATION: Stein PD, Matta F, Hughes PG, et CLINICAL QUESTION: Is fecal microbiota defined as occurring between 7 p.m. and Updated recommendations for al. Home treatment of pulmonary embo- transplantation (FMT) an efficacious 6:59 a.m. Primary outcome was reintuba- 10managing gout tion; secondary outcomes were ICU and CLINICAL QUESTION: What are the new treat- hospital mortality and ICU and hospital ment options for gout? length of stay. BACKGROUND: The 2006 European League The use of VKA in the first 3 months after a bioprosthetic Only one-fifth of patients with MV Against Rheumatism (EULAR) guide- underwent overnight extubations. For MV lines recommend that acute flares of gout valve implantation does not decrease the rate of throm- duration of at least 12 hours, rates of reintu- be treated as early as possible with either bation were higher for patients undergoing oral colchicine, oral corticosteroids, or boembolic events or mortality, but it is associated with overnight extubation (14.6% vs. 12.4%; P intra-articular corticosteroids. Experts less than .001). Mortality was significantly recommend starting urate-lowering ther- increased risk of major bleeding. higher for patients undergoing overnight apy (ULT) only when certain severe clini- versus daytime extubation in the ICU cal features occur, such as recurrent acute (11.2% vs. 6.1%; P less than.001) and in attacks and tophi. the hospital (16.0% vs. 11.1%; P less than STUDY DESIGN: Systematic review. lism in the era of novel oral anticoagulants. and safe treatment approach for patients .001). Length of ICU and hospital stays did SETTING: EULAR task force members from Am J Med. 2016;129(9):974-977. with recurrent Clostridium difficile infec- not differ. 12 European countries. tion (CDI)? BOTTOM LINE: Overnight extubations occur SYNOPSIS: Since the last guidelines, interleu- Dr. Gummalla is an assistant professor at the BACKGROUND: FMT restores the normal in one of five patients in U.S. ICUs and are kin-1 blockers (IL-1) were found to play a University of Miami Miller School of Medi- composition of gut microbiota and is associated with worse outcomes, compared crucial role in crystal-induced inflamma- cine and a hospitalist at University of Miami recommended when antibiotics fail to with daytime extubations. tion. IL-1, NSAIDs, and corticosteroids Hospital and Jackson Memorial Hospital. clear CDI. To date, only case series and CITATION: Gershengorn HB, Scales DC, should be considered in patients with open-labeled clinical trials support the use Kramer A, Wunsch H. Association between frequent flares and contraindications to By Aymara Fernandez de la Vara, of FMT. overnight extubations and outcomes in the colchicine. MD STUDY DESIGN: Randomized, controlled, intensive care unit. JAMA Intern Med. Unlike in the previous guidelines, ULT double-blinded clinical trial. 2016;176(11):1651-1660. should be considered from first presenta- Non–vitamin K antagonist oral SETTING: Academic medical centers. tion of gout; for severe disease, serum uric 12anticoagulants for planned SYNOPSIS: This study included 46 patients Vent bundles and ventilator- acid (SUA) levels should be maintained at atrial  brillation cardioversions with three or more recurrences of CDI 15associated pneumonia less than 6 mg/dL and less than 5 mg/dL. CLINICAL QUESTION: How does edoxaban who received a course of vancomycin for outcomes Allopurinol is recommended for first- compare with enoxaparin-warfarin in their most recent acute episode. FMTs CLINICAL QUESTION: Are the components of line ULT, and if the SUA target cannot be patients with nonvalvular atrial fibrillation with donor stool or patient’s stool (autol- the ventilator bundles (VBs) associated reached, it should be switched to another undergoing cardioversion? ogous) were administered by colonos- with better outcomes for patients? xanthine oxidase inhibitor (febuxostat) or BACKGROUND: Studies on non–vitamin K copy. BACKGROUND: VBs have been shown to a uricosuric or combined with a uricosuric. antagonist oral anticoagulants (NOACs) The primary endpoint was resolution prevent ventilator-associated pneumonia Pegloticase is recommended for refractory for patients with nonvalvular atrial fibrilla- of diarrhea without anti-CDI therapy (VAP). However, most of the studies have gout. tion undergoing cardioversion are limited. after 8 weeks of follow-up. In the donor analyzed outcomes based on the whole BOTTOM LINE: The updated 2016 EULAR STUDY DESIGN: Multicenter, prospective, FMT group, 90.9% achieved clinical cure, bundle without considering each individual guidelines recommend new treatment randomized trial. compared with 62.5% in the autologous component. options for gout and updated indications SETTING: Nineteen countries at 239 study group. Patients who developed recurrent STUDY DESIGN: Retrospective cohort study. for ULT. sites. CDI were free of further disease after subse- SETTING: Brigham and Women’s Hospital CITATION: Richette P, Doherty M, Pascual SYNOPSIS: This trial compared edoxaban quent donor FMT. in Boston. E, et al. 2016 updated EULAR evidence- with enoxaparin-warfarin. The study was The study included only patients who SYNOPSIS: Individual VB components based recommendations for the manage- stratified by cardioversion approach, antico- experienced three or more recurrences but were investigated among 5,539 patients ment of gout [published online ahead of agulant experience, selected edoxaban dose, excluded immunocompromised and older undergoing mechanical ventilation for print July 25, 2016]. Ann Rheum Dis. doi: and region. There were 2,199 patients, patients (older than 75 years of age). at least three days. Outcomes reported BOTTOM LINE: 10.1136/annrheumdis-2016-209707. mean age was 64, mean CHA2DS2-VASc Donor stool administered were ventilator-associated events (VAEs), score was 2.6, and mean therapeutic time via colonoscopy was more effective than extubation alive versus ventilator mortal- Home treatment of PE remains on warfarin was 70.8%. autologous FMT in preventing further ity, and hospital discharge versus hospital 11rare The primary efficacy endpoint was a CDI episodes. death. CLINICAL QUESTION: What is the prevalence composite of stroke, systemic emboli, CITATION: Kelly CR, Khoruts A, Staley C, et Spontaneous breathing trials were asso- of outpatient treatment of acute pulmonary myocardial infarction, and cardiovascu- al. Effect of fecal microbiota transplantation ciated with lower hazards for VAEs (HR, embolism (PE)? lar mortality, which occurred in 5 (1%) on recurrence in multiply recurrent Clostrid- 0.55; 95% CI, 0.40-0.76; P less than .001) BACKGROUND: PE traditionally is perceived patients in the edoxaban group versus 11 ium difficile infection: a randomized trial. and infection-related ventilator-associated as a serious condition requiring hospi- (1%) in the enoxaparin-warfarin group Ann Intern Med. 2016;165(9):609-616. complications (IVACs) (HR, 0.60; 95% talization. Many studies, however, have (odds ratio, 0.46; 95% CI, 0.12-1.43). CI, 0.37-1.00; P = .05). Head-of-bed shown that outpatient treatment of PE in The primary safety endpoint was major Dr. Fernandez de la Vara is an instructor elevation (HR, 1.38; 95% CI, 1.14-1.68; low-risk, compliant patients is safe. Several and clinically relevant nonmajor bleeding at the University of Miami Miller School of P = 0.001) and thromboembolism proph- scoring systems have been derived to iden- for patients receiving at least one dose of the Medicine and chief medical resident at the ylaxis (HR, 2.57; 95% CI, 1.80-3.66; P tify patients with PE who are at low risk of study drug, occurring in 16 (1%) of 1,067 University of Miami Hospital. less than .001) were associated with less adverse events and may be candidates for patients given edoxaban versus 11 (1%) of time to extubation. home treatment. 1,082 patients given enoxaparin-warfarin By Maria Antonietta Mosetti, MD Oral care with chlorhexidine was associ- STUDY DESIGN: Retrospective cohort study. (OR, 1.48; 95% CI, 0.64-3.55). ated with lower hazards for IVACs (HR, SETTING: Five U.S. EDs. BOTTOM LINE: In patients with nonvalvu- Overnight extubations associated 0.60; 95% CI 0.36-1.00; P = .05) and for SYNOPSIS: Among 983 patients diagnosed lar atrial fibrillation undergoing cardio- 14with worse outcomes VAPs (HR, 0.55; 95% CI, 0.27-1.14; P with acute PE, 237 (24.1%) were unsta- version, edoxaban had low rates of major CLINICAL QUESTION: Are overnight extuba- = .11) but an increased risk for ventila- ble and hypoxic. Only a small proportion bleeding and thromboembolism similar tions in intensive care units associated CONTINUED ON PAGE 16

www.the-hospitalist.org I JANUARY 2017 I THE HOSPITALIST 15 IN THE LITERATURE I continued from page 15 tor mortality (HR, 1.63; 95% CI, 1.15- and death (5.4%). Seventeen percent of all 2.31; P = .006). Stress ulcer prophylaxis patients who received IV antibiotics were was associated with higher risk for VAP Low-risk FN patients in the ED received more aggressive prescribed vancomycin without guideline (HR, 7.69; 95% CI, 1.44-41.10; P = .02). support. BOTTOM LINE: Standard VB components treatment than recommended. Further research is need- BOTTOM LINE: Low-risk FN patients in the merit revision to increase emphasis on ed to strategize means of better aligning FN management ED received more aggressive treatment beneficial components and eliminate than recommended. Further research potentially harmful ones. with standards of care. is needed to strategize means of better CITATION: Klompas M, Li L, Kleinman aligning FN management with standards K, Szumita PM, Massaro AF. Associa- of care. tion between ventilator bundle compo- CITATION: Baugh CW, Wang TJ, Caterino nents and outcomes. JAMA Intern Med. By Jessica Zuleta, MD, FHM BACKGROUND: Chemotherapy-related FN JM, et al. ED management of patients 2016;176(9):1277-1283. is an oncologic emergency frequently with febrile neutropenia: guide- Do not overtreat febrile leading to hospitalization and intravenous line concordant or overly aggressive Dr. Mosetti is an assistant professor at 16neutropenia antibiotics. Familiarity with FN guidelines [published online ahead of print Sept. 9, the University of Miami Miller School of CLINICAL QUESTION: Does emergency depart- allows risk stratification for inpatient versus 2016]? Acad Emerg Med. doi: 10.1111/ Medicine and a hospitalist at University ment management of patients with febrile outpatient therapy. acem.13079. of Miami Hospital and Jackson Memorial neutropenia (FN) follow current guide- STUDY DESIGN: Single-center, retrospective, Hospital. lines? cohort study. What to do with isolated calf SETTING: Large, urban, tertiary-care 17DVT academic hospital. CLINICAL QUESTION: Does therapeutic antico- ADDITIONAL REVIEWS AT SYNOPSIS: Of 173 patient visits, 25% agulation of isolated calf deep vein throm- were risk stratified as eligible for outpa- bosis (DVT) decrease risk for proximal THE-HOSPITALIST.ORG tient treatment and 75% as inpatient care. DVT or PE? All patient care was assessed for guideline BACKGROUND: Optimal management of concordance at the time of ED disposition isolated calf DVT lacks consensus. • Drug-eluting stents similar to bare-metal stents on mortality and therapy. STUDY DESIGN: Single-center, retrospective, • Dexmedetomidine reduces postop delirium Primary outcome analysis demonstrated cohort study. management was guideline discordant in SETTING: Large academic hospital. For more physician review of HM-relevant 98% of low-risk patients versus 7% of high- SYNOPSIS: Researchers evaluated 14,056 risk patients. Secondary 30-day clinical lower-extremity venous duplex studies research, visit the-hospitalist.org. outcomes showed high-risk patients were and identified 243 patients with an intent more likely to have positive blood cultures to treat with therapeutic anticoagulation (54%), sepsis-induced hypotension (9.3%), as well as 141 patients without anticoagu-

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16 THE HOSPITALIST I JANUARY 2017 I www.the-hospitalist.org lation. The primary outcome was radio- proximal DVT or PE. The anticoagulation for isolated calf DVT may be warranted Surg. 2016;151(9):e161770. doi: 10.1001/ graphic confirmation of proximal DVT or group was associated with lower likelihood to decrease the risk for proximal DVT or jamasurg.2016.1770. PE within 180 days of initial study. Dura- of proximal DVT or PE (risk ratio 0.36; PE but with an increased risk of bleeding. tion of anticoagulation, timing of radio- 95% CI, 0.15-0.84) but an increased risk of Randomized trials are needed to clarify the Dr. Zuleta is an assistant professor and associ- graphic follow-up, and frequency of follow- bleeding (8.6%), compared with the nonex- risk versus benefit. ate program director of the Jackson Memorial/ up within the first 180 days were varied. posure group (2.2%). Sensitivity analysis CITATION: Utter GH, Dhillon TS, Salcedo University of Miami Internal Medicine resi- Nevertheless, 9.2% of control patients did not alter the observed association. ES, et al. Therapeutic anticoagulation for dency training program and the site director of and 3.3% of exposure patients developed a BOTTOM LINE: Therapeutic anticoagulation isolated calf deep vein thrombosis. JAMA the program at University of Miami Hospital.

PEDIATRIC HM LITERATURE I By Weijen W. Chang, MD, FAAP, FACP, SFHM Pleth Variability Index shows promise for asthma assessments Does pulse variability on plethysmography, or the Pleth Variability Index, correlate with disease severity in obstructive airway disease in children?

CLINICAL QUESTION: Does pulse variability on plethysmography, or the Pleth Variability TABLE 1 Criteria for disposition from ED Index (PVI), correlate with disease Disposition location Criteria severity in obstructive airway disease in Dr. Chang is children? hNo oxygen requirement pediatric editor of BACKGROUND: Asthma is the most common Discharge hInhaled bronchodilator therapy not more The Hospitalist. reason for hospitalization in the United frequent than every 4 hours He is associate States for children 3-12 years old. h FiO requirement <0.5 clinical professor 2 Asthma accounts for a quarter of ED General pediatrics floor h Inhaled bronchodilator therapy required every of pediatrics at visits for children aged 1-9 years old.1 the University of 2–4 hours Although systems have been developed h FiO requirement ≥0.5 Massachusetts, to assess asthma exacerbation severity 2 Worcester, and chief h Need for invasive or noninvasive positive and the need for hospitalization, many pressure ventilation of pediatric hospital ICU of these depend on reassessments over h Inhaled bronchodilator therapy required more medicine at Baystate time or have been proven to be invalid Children’s Hospital, 2-4 frequently than every 2 hours in larger studies. Pulsus paradoxus h Need for bronchodilator infusion Springfield, Mass. (PP), which is defined as a drop in Send comments and systolic blood pressure greater than 10 questions to Weijen. mm Hg, correlates with the severity of [email protected]. obstruction in asthma exacerbations, TABLE 2 PVI according to disposition but it is not practical in the children being evaluated in the ED or hospital.5,6 PP Disposition Median PVI measurement using plethysmography Discharged to home 0.27 (IQR, 0.19–0.39) has been found to correlate with measurement by sphygmomanometry.7 Admitted to general pediatrics floor 0.29 (IQR, 0.20–0.44) Furthermore, PVI, which is derived from Admitted to PICU 0.56 (IQR, 0.35–0.70) amplitude variability in the pulse oximeter waveform, has been found to correlate with fluid responsiveness in mechanically the initial evaluation to determine variability as a triage tool for children ventilated patients. To this date, no study disposition from the ED, which included with obstructive airway disease in has assessed the correlation between PVI either discharge to home, admission to a a pediatric emergency department and exacerbation severity in asthma. general pediatrics floor, or admission to [published online ahead of print Oct. 6, STUDY DESIGN: Prospective observational the PICU. The hospital utilized specific 2016]. Pediatr Emerg Care. doi: 10.1097/ study. criteria for disposition from the ED (see PEC.0000000000000887. SETTING: A 137-bed, tertiary-care children’s Table 1). hospital. Of the 117 patients who were analyzed References SYNOPSIS: Over a 6-month period on after application of exclusion criteria, 1. Care of children and adolescents in U.S. hospitals. Agency for weekdays, researchers enrolled patients 48 were discharged to home, 61 were Healthcare Research and Quality website. Available at https:// archive.ahrq.gov/data/hcup/factbk4/factbk4.htm. Accessed aged 1-18 years evaluated in the ED admitted to a general pediatrics floor, Nov. 18, 2016. for asthma exacerbations or reactive and eight were admitted to the PICU. 2. Kelly AM, Kerr D, Powell C. Is severity assessment after one airway disease. ED staff diagnosed The three groups were found to be hour of treatment better for predicting the need for admission patients clinically, and other patients with demographically similar. Researchers in acute asthma? Respir Med. 2004;98(8):777-781. conditions known to affect PP – such as found a significant difference between 3. Keogh KA, Macarthur C, Parkin PC, et al. Predictors of hospitalization in children with acute asthma. J Pediatr. dehydration, croup, and cardiac disease the PVI of the three groups, but pairwise 2001;139(2):273-277. – were excluded. PVI was calculated by analysis showed no significant difference 4. Keahey L, Bulloch B, Becker AB, et al. Initial oxygen satura- measuring the minimum perfusion index between the PVI of patients admitted tion as a predictor of admission in children presenting to the (PImin) and the maximum perfusion index to the general pediatrics floor versus emergency department with acute asthma. Ann Emerg Med. 2002;40(3):300-307. (PImax) using the following formula: discharged to home (see Table 2). 5. Guntheroth WG, Morgan BC, Mullins GL. Effect of respiration on BOTTOM LINE: PVI shows promise as a tool venous return and stroke volume in cardiac tamponade. Mech- PVI = ______PImax - PImin to rapidly assess disease severity in anism of pulsus paradoxus. Circ Res. 1967;20(4):381-390. PImax pediatric patients being evaluated and 6. Frey B, Freezer N. Diagnostic value and pathophysiologic basis treated for asthma, but further studies of pulsus paradoxus in infants and children with respiratory disease. Pediatr Pulmonol. 2001;31(2):138-143. A printout of the first ED pulse oximetry are needed to validate this in the ED and 7. Clark JA, Lieh-Lai M, Thomas R, Raghavan K, Sarnaik AP. reading was used to obtain the PImax hospital setting. Comparison of traditional and plethysmographic methods and PImin as below: CITATION: Brandwein A, Patel K, Kline M, for measuring pulsus paradoxus. Arch Pediatr Adolesc Med. Researchers followed patients after Silver P, Gangadharan S. Using pleth 2004;158(1):48-51.

www.the-hospitalist.org I JANUARY 2017 I THE HOSPITALIST 17 What lies ahead?

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“It was a strong achievement to get 20 Fund, Dr. Eibner investigated the economic Experts say the plans put more onus on ACA since more patients were insured. million people insured, but it’s not clear that implications of aspects of Mr. Trump’s plans individuals and may raise their costs. For Joshua Lenchus, DO, RPh, FACP, SFHM, it bent the cost curve,” says Dr. Eibner. “There as a candidate. Using a computer model that example, Price’s plan would offer premium a member of SHM’s Public Policy Commit- are high premiums on the individual market incorporates economic theory and data to tax credits based on age, rather than income, tee, and hospitalist at the University of and still 31 million people without coverage. simulate the effects of health policy changes, with a maximum of $3,000 available to Miami/Jackson Memorial Hospital, is no There is still opportunity to improve.” he found that Mr. Trump’s plans (full repeal individuals older than 55 years. fan of entitlement programs such as Medic- alone or repeal with tax deductions for health “Young, healthy, and wealthy people may aid but says, “The safety-net hospital where I Where we stand January 2017 care premiums, Medicaid block grants, or sell- do quite well under this vision of health care work would rather have people covered with Whether the Republicans can or will repeal ing health insurance across state lines) would reform,” Larry Levitt, a senior vice president something than nothing.” the ACA in its entirety and improve it increase the number of uninsured people by at the nonpartisan Kaiser Family Founda- Dr. Lenchus is optimistic that economic remains unknown. It could take months 16 million to 25 million, disproportionately tion, told Politico in November. “But reforms under Trump will lead to more jobs, or even years to replace. But, the experts impact low-income and sicker patients, expose people who are older, poorer, and sicker increasing the number of people covered by say, the landmark law has left its mark on individual market enrollees to higher out-of- could do a lot worse.” employer plans. “The economy drives health the American health care system. pocket costs, and increase the federal deficit “While the approach puts more risk on the care reform,” he says. “He has to up his ante “Everyone is complaining about the by $0.5 billion to $41 billion.1 consumer, it makes government spending now and show people that he can stimulate job uncertainty created by the election, but The Congressional Budget Office more predictable than if the credit amount growth in this country so we don’t have this we have been dealing with a highly uncer- (CBO) estimates full repeal could increase were tied to premium prices,” says Dr. Eibner. middle class that is continuously squeezed.” tain environment for many years,” says the federal deficit by $137 billion to $353 “By divorcing the credit amount from health Dr. Greeno and Ms. Hoffman, who is also Ron Greeno, MD, FCCP, MHM, senior billion by 2025.2 care cost growth, the approach may help to a faculty associate at the UCLA Center for adviser for medical affairs at TeamHealth, Rep. Ryan’s A Better Way plan and Price’s constrain the growth of the deficit.” Health Policy Research and vice chair of the chair of the SHM Public Policy Commit- Empowering Patients First Act propose Dr. Eibner says there is “a clear implica- Insurance Law Section of the Association of tee, and SHM president-elect. “There will providing people more control over their tion” that physicians may lose patients, care American Law Schools, suggest hospitalists get be changes, but things were going to change health care, giving tax credits instead of subsi- for a greater share who are uninsured, and see involved as rules are being shaped and written. no matter the outcome of the election. It dies for premiums, capping the employer- a return of higher rates of uncompensated “We want to help reform the delivery continues to require tolerance for change sponsored health insurance tax exclusion, and hospital care. The experts say Republicans system, and we want it to be done right and and tolerance for uncertainty.” expanding use of health savings accounts.3 are unlikely to restore cuts to disproportion- to be done fairly. We want to have say in how In an analysis for the Commonwealth However, specific details vary between them. ate-share hospitals that were made under the our patients are treated,” Dr. Greeno says.

18 THE HOSPITALIST I JANUARY 2017 I www.the-hospitalist.org Everyone is complaining about the uncertainty created by the election, but we have been dealing with a highly uncertain environment for many years. There will be changes, but things were going to change no matter the outcome of the election. It continues to require tolerance for change and tolerance for uncertainty. –Ron Greeno, MD, FCCP, MHM, senior adviser for medical affairs at TeamHealth, chair of the SHM Public Policy Committee, and SHM president-elect

Key provisions: A Medicaid. Dr. Greeno calls this a “massive was prolonged, and though the reasons are of the health benefits it required of plans on delicate balance political challenge” unless they can provide not clear, Medicare spending has slowed the individual market. For example, policy- Many people equate the ACA with the indi- an alternative way to cover people who since the passage of the ACA.6 makers might be allowed to strip the contra- vidual mandate, which requires nearly all currently rely on the federal-state entitle- ceptive coverage regulation, which provides Americans to purchase health insurance or ment, as well as those who gained cover- MACRA launch for free birth control. pay a fine. The federal government provides age through ACA expansion. Currently, 70 Another key factor in the health care “The reality is a lot of things changing subsidies to enrollees 138% - 400% of the million people are enrolled in Medicaid and policy landscape is MACRA, the Medi- in health care now were changing before federal poverty level so their out-of-pocket the Children’s Health Insurance Program.5 care Access and CHIP Reauthorization the Affordable Care Act passed – PQRS, costs never exceed a defined threshold, even Through Mr. Trump’s suggested block Act, which fundamentally shifts the value-based purchasing, hospital-acquired if premiums go up. These could be on the grants, states would receive a fixed amount way the government administrates and infections,” Dr. Greeno says. “MACRA chopping block. of money to administer their program with reimburses physicians for health care. will continue the journey away from fee- “The last bill Congress passed to repeal increased flexibility. Rep. Ryan’s plan calls MACRA begins in 2017. Dr. Greeno is for-service toward outcome-based models.” the Affordable Care Act, which Obama for enrollment caps that would distribute concerned that changes to the ACA will At such a pivotal time, he strongly vetoed, repealed the individual mandate a dollar amount to each participant in the affect CMS’ testing of payment models. encourages hospitalists to join SHM if they and subsidies for people to buy insurance,” program with no limit on the number of “There are hundreds of hospitals and are not already members and to get involved Ms. Hoffman says. “If they do repeal it, enrollees. Either would be adjusted for private insurance through the exchanges inflation. Price may make it easier for states will crumble.” to obtain waivers. There is no clear coalescence around The tax deductions to offset premium Under Rep. Ryan’s and Rep. Price’s plans, costs that Trump proposed as a candidate states could implement work requirements specific policy reforms that would are based on income, making them more for beneficiaries or ask them to pay toward generous for higher-income earners than their premiums. Expansion states could also replace the Affordable Care Act. low-income ones, Hoffman adds. lower the Medicaid threshold below 138%. Additionally, “premiums go way up Some states will struggle to provide –Christine Eibner, PhD, a senior economist at Rand and a because many more people can’t afford for all their enrollees, Ms. Hoffman says, professor at the Pardee Rand Graduate School. insurance, so those who choose to buy are particularly since health spending gener- the sickest,” says Ms. Hoffman. “Risk pools ally outpaces inflation. Dr. Lenchus is get extremely expensive, and many more more optimistic. “I believe states that didn’t thousands of physicians already invested in SHM’s Grassroots Network. people see it as unaffordable.” As a result, expand Medicaid, one way or another, will in different models, so I don’t expect “For a society of our age – young – and she says, people may choose high-deductible figure out a way to deal with that popula- anybody has any desire to pull the rug from size, we’ve been tremendously impactful plans and face high out-of-pocket costs if tion,” he says. under physicians who are testing alterna- in helping with delivery system reform,” they do seek care. tive payment models [APMs],” he says. Dr. Greeno says. “I think it’s because we’re “It’s asking individuals to save by decid- And … Medicare “MACRA was passed on a strong bipartisan supporting change, not trying to stop it. We ing how they’re going to ration care, where The other entitlement program facing vote, and it created an APM track. Obvi- just want it to be intelligent change.” someone says they’re not going to go to the abrupt change is Medicare, typically consid- ously, Congress intended APM models to He also is “convinced” hospitalists will doctor today or fill a prescription drug they ered the third rail of American politics. continue to expand.” be “critical to the redesign of the health care need,” she said. “This is the hot political moment,” Ms. Testing of these models could slow if system. Since we are going to be taking care Meanwhile, Mr. Trump has said he would Hoffman says. “This is the point where the Republicans enact changes to CMMI, says of the majority of hospitalized adult patients like to keep the provision of the ACA that Republicans think they can tick off their Dr. Greeno. in hospitals, hospitalists want to have our bans insurers from denying individuals with wish list. For many Republicans, this kind Hospitalists are helping “shape these say.” preexisting conditions. This, experts agree, of entitlement program is the opposite of models,” working with CMS and the Physi- may not be possible if other parts of the law what they believe in.” cian-Focused Payment Model Technical Kelly April Tyrrell is a freelance writer in are repealed and not replaced with similar Though Mr. Trump has said before he Advisory Committee “to ensure physicians Madison, Wis. protections for insurers. would not alter Medicare, he remained participate in APMs and feel engaged rather “If you try to keep the rules about not quiet on this point in the aftermath of the than being a worker in a model someone References including preexisting conditions and get rid election. Repealing the ACA would affect else controls.” 1. Eibner C. Donald Trump’s health care reform proposals: of subsidies and the individual mandate, it Medicare by potentially reopening the Part On the campaign trail, Mr. Trump spoke Anticipated effects on insurance coverage, out-of-pocket costs, and the federal deficit. The Commonweath Fund just won’t work,” Ms. Hoffman says. “You D prescription drug doughnut hole and of importing pharmaceuticals from over- website. Available at http://www.commonwealthfund.org/ end up with extraordinarily expensive eliminating some of the savings provisions seas in an effort to control high prices. This publications/issue-briefs/2016/sep/trump-presidential- health insurance.” in the law. In fact, the CBO estimates Medi- policy is no longer part of his online plan. health-care-proposal. Accessed Nov. 17, 2016. Rep. Ryan’s and Rep. Price’s plans would care’s direct spending would increase $802 He also proposes allowing the sale of health 2. Budgetary and economic effects of repealing the Afford- 1 able Care Act. Congressional Budget Office website. prohibit insurers from denying patients with billion between 2016 and 2025. insurance across state lines. Available at https://www.cbo.gov/sites/default/ preexisting conditions but only if patients Rep. Ryan and Rep. Price have discussed “It would be giving enrollees in states with files/114th-congress-2015-2016/reports/50252- maintain continuous coverage, with a single privatizing Medicare by offering seniors stricter regulations the opportunity to circum- Effects_of_ACA_Repeal.pdf. Accessed Nov. 15, 2016. open-enrollment period. Ryan has also- vouchers to apply toward private insurance. vent to a looser state, which undermines the 3. Our vision for a confident America. A Better Way website. Available at: http://abetterway.speaker.gov. Accessed promised to provide at least $25 billion in “At the highest level, it’s moving Medicare state with the stricter regulations,” Dr. Eibner Nov. 17, 2016. federal funding for state high-risk pools. from a defined benefit to a defined contri- says. “That would really create winners and 4. Pollitz K. High-risk pools for uninsurable individuals. Prior to the passage of the ACA, 35 states bution program,” Ms. Hoffman says. “It losers. People who are healthy can buy a policy Kaiser Family Foundation website. Available at http://kff. offered high-risk pools to people excluded shifts financial risk from the federal govern- in a state with looser regulations, and their org/health-reform/issue-brief/high-risk-pools-for-unin- from the individual market. The Kaiser Family ment onto beneficiaries. If Medicare spend- costs would likely fall. But someone sicker and surable-individuals/. Accessed Nov. 17, 2016. Foundation shows the net annual losses in ing continues to grow faster than the rest older, it would be harder.” 5. How accessible is individual health insurance for consum- ers in less-than-ideal health? Kaiser Family Foundation these states averaged $5,510/ enrollee in 2011. of the economy, Medicare beneficiaries will Ms. Hoffman defines such a plan as a website. Available at https://kaiserfamilyfoundation.files. Premiums ranged from 100% to 200% higher pay more and more.” “race to the bottom.” Without well-estab- wordpress.com/2013/01/how-accessible-is-individual- than non–high-risk group coverage. Govern- Seniors may also find themselves ration- lished networks of physicians and hospitals, health-insurance-for-consumer-in-less-than-perfect- health-report.pdf. Accessed Nov. 17, 2016. ment subsidies to cover losses amounted to $1 ing or skimping on care. startup costs in new states are prohibitive, 4 6. The Affordable Care Act and Medicare. The Common- billion in each state. Despite Rep. Ryan’s statements to the and many insurers may not wish to compete wealth Fund website. Available at http://www.common- Meanwhile, both Mr. Trump and Rep. contrary, Medicare is not broken because across state lines, she adds. wealthfund.org/publications/fund-reports/2015/jun/ Ryan have proposed profound changes for of the ACA, Ms. Hoffman says. Its solvency Repeal of the ACA could also limit some medicare-affordable-care-act Accessed Nov. 17, 2016.

www.the-hospitalist.org I JANUARY 2017 I THE HOSPITALIST 19 NEWS I Clinical developments, health care policy, and regulations Heart failure readmission metric not linked to care quality

BY ALICIA GALLEGOS sion rate vs. 96.5% for those with high risk- by CMS to determine readmission penal- metric in identifying and penalizing hospitals Frontline Medical News adjusted rate) for median adherence to all ties are not associated with quality of care with low quality of care,” Dr. Pandey wrote, performance measures, as was the case for or overall clinical outcomes, Dr. Pandey adding that the findings were consistent with FROM THE AHA SCIENTIFIC SESSIONS median percentage of defect-free care (90.0% and his colleagues wrote. Results showing previous studies that have demonstrated a lack etrics used by the Centers for vs. 91.1%, respectively) and composite higher 30-day readmissions do not neces- of association between in-hospital quality of Medicare & Medicaid Services to care and 30-day readmission rates. Mdetermine penalties for heart fail- CMS implemented the federal Hospital ure hospital readmissions are not associ- Taken together, the findings suggest the 30-day Readmissions Reduction Program (HRRP) ated with quality of care or overall clinical in 2012 to provide financial incentives for outcomes, according to data presented at readmission metrics currently used by CMS to determine hospitals to reduce readmissions. Under the the annual scientific sessions of the Amer- program, CMS uses claims data to deter- ican Heart Association. readmission penalties are not associated with quality of mine whether readmission rates for heart Ambarish Pandey, MD, of the Univer- care or overall clinical outcomes. failure, acute myocardial infarction, and sity of Texas Southwestern Medical Center pneumonia at eligible hospitals are higher in Dallas, and his colleagues analyzed data —Ambarish Pandey, MD than would be predicted by CMS models. from centers participating in the American Centers with higher than expected readmis- Heart Association’s Get With The Guide- sion rates face up to a 3% reimbursement lines–Heart Failure (GWTG-HF) registry 1-year outcome of death or all-cause read- sarily reflect poor quality of care and may penalty. linked to Medicare claims from July 2008 mission rates (median 62.9% vs. 65.3%, be related to other factors. to June 2011. Centers were stratified as respectively). The higher readmission group “These findings question the usefulness of [email protected] having low risk-adjusted readmission rates had higher 1-year all-cause readmission rates the [hospital readmission reduction program] On Twitter @legal_med and high risk-adjusted readmission rates (median, 59.1% vs. 54.7%), Dr. Pandey and based on publicly available data from 2013. his colleagues reported in the study that was The study included 171 centers with published simultaneously in JACC: Heart 43,143 patients. Centers were almost evenly Failure (2016 Nov 15. doi: org/10.1016/j. Combine qSOFA and SIRS for split between low and high risk-adjusted jchf.2016). One-year mortality rates were 30-day readmission rates, with just a few lower in the higher readmission group with a more (51%) falling in the low risk-adjusted trend toward statistical significance (median, best sepsis score category. 28.2% vs. 31.7%; P = 0.07). Performance was nearly equal (95.7% for Taken together, the findings suggest the BY M. ALEXANDER OTTO investigator Eli Finkelsztein, MD, of the centers with a low risk-adjusted readmis- 30-day readmission metrics currently used Frontline Medical News New York–Presbyterian Hospital. The second study – a review of 6,811 severe AT CHEST 2016 sepsis/septic shock patients scored by both LOS ANGELES – Instead of replacing systems within 3 hours of emergency depart- the Systemic Inflammatory Response ment admission at the University of Kansas State of Syndrome (SIRS) score with the new Hospital emergency department in Kansas Hospital quick Sequential Organ Failure Assess- City – found that the two scores performed Medicine ment (qSOFA) score to identify severe largely the same when it came to predicting 2016 Report sepsis patients, it might be best to use both, ICU admission and 30-day mortality, but that according to two studies presented at the people who met two or more criteria in both American College of Chest Physicians systems were of special concern. NOW AVAILABLE annual meeting. Twenty-five percent of patients (1,713) The gold standard 3rd International scored 2 or more on both SIRS and qSOFA. Consensus Definitions for Sepsis and These patients were more likely to be admit- Stay on top of Septic Shock Task Force recently intro- ted to the ICU and be readmitted to the the evolving duced qSOFA to replace SIRS, in part hospital after a month, compared with those because SIRS is too sensitive. With criteria patients who were positive in only one scor- trends in hospital that include a temperature above 38° C, a ing system or negative in both. Additional medicine. heart rate above 90 bpm, and a respiratory factors associated with these patients were rate above 20 breaths per minute, it’s possi- that they had the longest ICU and hospital ble to score positive on SIRS by walking up lengths of stay. Two hundred (12%) of these a flight of stairs, audience members at the patients scoring 2 or more on both SIRS study presentations noted. and qSOFA died within 30 days. The first study at the meeting session – a “SIRS criteria continue to be more sensi- Median prospective cohort of 152 patients scored by tive at identifying severe sepsis, but they are compensation both systems within 8 hours of ICU admis- equally as accurate [as qSOFA criteria] at sion at the New York–Presbyterian Hospital predicting adverse patient outcomes,” said rose 10.2% – found that qSOFA was slightly better at lead investigator and Kansas University from $252,996 Nocturnist predicting in-hospital mortality and ICU- medical student Amanda Deis. free days, but no better than SIRS at predict- SIRS and qSOFA take only a few seconds in 2014 to employment ing ventilator- or organ failure–free days. to assess at the bedside. Using both builds $278,746 in 2016. has risen from However, of the 36% of patients (55) “a clinical picture,” she said. 58.3% in 2014 who met only one of the three qSOFA There was no industry funding for the criteria – a respiratory rate of 22 breaths per work, and the investigators had no relevant to 72.3% in 2016. minute, altered mental status, or a systolic financial disclosures. blood pressure of 100 mg Hg or less – 6% (3) died in the hospital. Of those patients, [email protected] Get the rest of the data from the 2016 Report in the two-thirds (2) were SIRS positive, meaning enhanced digital version or the traditional print version. that they met two or more SIRS criteria. “Having a borderline qSOFA of 1 point, LEARN MORE Order Today at which is considered negative, with the addi- www.hospitalmedicine.org/SoHM tion of having SIRS criteria, should raise For more information on concerns that patients need further evalua- joining SHM, visit www.hospitalmedicine.org. tion. SIRS criteria should not be [entirely] discarded” in favor of qSOFA, said lead

20 THE HOSPITALIST I JANUARY 2017 I www.the-hospitalist.org Make your next smart move. Visit www.shmcareers.org

Create your legacy Hospitalists Hospital Medicine Faculty Positions Legacy Health The Section of Hospital Medicine at Vanderbilt Portland, Oregon University Medical Center seeks well-trained BC/BE Internal Medicine physicians to join the Extensivist At Legacy Health, our legacy is doing what’s best for our patients, our people, our community and our world. Program at the level of Assistant, Associate, or Our fundamental responsibility is to improve the health of everyone and everything we touch–to create a full Professor, on a clinical track. Physicians in this legacy that truly lives on. program, in conjunction with an interdisciplinary team, provide longitudinal inpatient, outpatient and care Ours is a legacy of health and community. Of respect and responsibility. Of quality and innovation. It’s the legacy across transitions, to patients at risk of increased we create every day at Legacy Health. healthcare utilization. We offer flexible scheduling, access to top specialists, And, if you join our team, it’s yours. and opportunities to engage in teaching, quality improvement, and scholarship. Vanderbilt University Located in the beautiful Pacific Northwest, Legacy is currently seeking experienced Hospitalists to join our Medical Center is a leader in providing high-quality, dynamic and well established yet expanding Hospitalist Program. Enjoy unique staffing and flexible scheduling cost-effective care. With robust programs in quality with easy access to a wide variety of specialists. You’ll have the opportunity to participate in inpatient care and improvement and clinical research, a highly-developed teaching of medical residents and interns. electronic health record, Magnet Recognition for nursing care, competitive salaries and benefits, and a Successful candidates will have the following education and experience: highly supportive environment for faculty, Vanderbilt is a great place to work. • Graduate of four-year U.S. Medical School or equivalent • Residency completed in IM or FP • Board Certified in IM or FP Please electronically submit a letter of interest and CV to: • Clinical experience in IM or FP [email protected] • Board eligible or board certified in IM or FP

The spectacular Columbia River Gorge and majestic Cascade Mountains surround Portland. The beautiful ocean beaches of the northwest and fantastic skiing at Mt. Hood are within a 90-minute drive. The temperate four-season climate, spectacular views and abundance of cultural and outdoor activities, along with five-star restaurants, sporting attractions, and outstanding schools, make Portland an ideal place to live.

As a nationally known and respected health care provider, Legacy Health offers an outstanding work K^h&ĂŶƐ͊/ƚ͛ƐƟŵĞƚŽĐŚĞĐŬŽƵƚƚŚĞƉŽƐƐŝďŝůŝƟĞƐ environment, competitive salary and comprehensive benefits. Learn more about us and apply on our website at www.legacyhealth.org. For additional information please contact Forrest Brown at (503) 415-5982 or toll free, (866) 888-4428. Email: [email protected]. AA/EOE/VETS/Disabled Our legacy is yours. &ƒ®Ù¥®›½—D›—®‘ƒ½›Äã›Ù >ĂŶĐĂƐƚĞƌ͕KŚŝŽ ǁǁǁ͘ƚŚĞD,'͘ĐŽŵϰϰϬ͘ϱϰϮ͘ϱϬϬϬ ^ĞŶĚsƚŽ: :ŽďƐΛdŚĞD,'͘ĐŽŵ ŽůƵŵďƵƐŝƐϯဒŵŝŶƵƚĞƐĂǁĂLJ͊

YOUR AD HERE!

Heather Gentile Linda Wilson 973.290.8259 or 973.290.8243 [email protected] [email protected]

Physicians You’re just one click away from your next job with the new SHM Career Center You’ve never had a more powerful ally in making your next career move. The new SHM Career Center is designed for busy doctors. Now you can: • Create job alerts • Quickly search for jobs on your smartphone • Save your jobs – works seamlessly! Create a candidate profile and get matched to your ideal job Find your next job today. Visit www.shmcareers.org

X To learn more, visit www.the-hospitalist.org and click on “Advertise” or contact Heather Gentile • 973.290.8259 • [email protected] or Linda Wilson • 973.290.8243 • [email protected]

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250 Pleasant Street, Concord, NH 03301 concordhospital.org Hospitalist Opportunity Sign On Bonus and Competitive Compensation Package

We are seeking a BE/BC hospitalist to join our well-established, collegial team of physicians and advanced providers. Francisco Loya, MD, MS The right candidate will have excellent clinical skills, a broad knowledge base and be dedicated to providing CEO, EmCare Hospital Medicine high quality, evidence-based care. As a member of this group, you will enjoy a collaborative work environment in an organization that is strongly committed to achieving the ideal work-life balance.

Concord Hospital is a 295-bed acute care facility and state Level II Trauma Center. MY HOSPITAL MEDICINE PASSION: CLINICAL QUALITY • One hour to Boston, the White Mountains and the Atlantic coast • Concord, New Hampshire’s state capital, provides all the energy, "I enjoy ensuring the standardization of clinical culture and opportunities of an urban city quality throughout Hospital Medicine Programs." • Surrounded by magni‹cent natural beauty and protected habitats • Local regional airport in Manchester, NH; 20 minutes from Concord • An abundance of outdoor activities like biking, boating, gol‹ng, skiing and hiking Pursue your passion for high-quality • Eclectic mix of dining, shopping and entertainment patient care with a state-of-the-art • Enjoy a lower cost of living with no state income tax or sales tax Hospitalist practice. • Excellent private & public school systems within close proximity to the hospital Contact: Jen Bubert (603)227-7079 [email protected] From cutting-edge tools and resources to innovative ickr.com/photos/26514027@N04/ practice opportunities, Hospitalists who work for EmCare enjoy an exceptional quality of practice.

Our physician-led company means you are supported by leadership on the local, regional and national level. Academic Chief for Hospitalist Division

From mentorship to leadership positions, EmCare oers the locations, positions and lifestyle you want nationwide. The University of Toledo Medical Center is seeking an Academic Chief for the Hospitalist Division. We are in search of a vibrant physician with a commitment to excellence who is also excited to lead and grow our Hospitalist division. The ideal candidate will work as a member of the leadership team in the Department of Medicine, as well as exhibit excep- tional clinical teaching, quality improvement, and administrative skills. Responsibilities include leadership, and oversight of the division as well as teaching, mentoring of students, residents and a commitment to facul- Please forward letters of ty development. This position will report to the Chair of the Department interest along with a copy of of Medicine. The University of Toledo is a nationally recognized center curriculum vitae to: of excellence for teaching. Significant opportunities for leadership and career developments.

EmCare locations The University of Toledo Position Qualifications: Medical degree from Accredited University, 855.367.3650 Health Science Campus, Search jobs at emcare.com/careers Ohio State Medical license, Board Eligible/ Board Certified in Internal Medicine, Must have prior Hospitalist experience, Possesses understand- Department of Medicine, ing of Ohio system, Committed to The University of Toledo’s core val- MS 1186, ues & serving the Toledo community, Excellent communication, bedside Toledo, Ohio 43614. manners, and organizational skills and A strong work ethic and desire to Telephone: (419) 383-5149 participate in a team oriented performance driven environment. Email: The University of Toledo is an Affirmative Action/ Equal Opportunity Employer. [email protected]

/RRNLQJWRȴOO To advertise in e Hospitalist or the Journal of Hospital Medicine, contact: an open position? Heather Gentile • 973.290.8259 [email protected] or Linda Wilson • 973.290.8243 [email protected]

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

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Excellent opportunity for a Hospital employed Hospitalist and practicing Hospitalist Program Director. The positions are inclusive of ICU responsibilities, which would include procedures such as vent management, intubation and central lines. Four Hospitalists provide 24/7 coverage to our 97 bed hospital, working a seven on-seven o schedule, and rotate days and nights every three months

Located in the Northeast, in the beautiful mountainous communities of Saranac Lake and Lake Placid, NY. Our climate, provides the full bene†ts of four seasons, and ample outdoor recreational activities such as hiking, skiing, golf, boating, biking, snowshoeing, or simply taking in the beauty of the surrounding Adirondack Mountains. We have been a two time host of the winter Olympics (1932 and 1980) and continue to host many sporting and world cup events, as well as the annual Ironman USA. These are safe, family friendly communities with excellent schools systems.

If you are interested in learning more about our opportunities, please contact Joanne Johnson at 518-897-2706, or e-mail [email protected]

Physician-Led Medicine in Montana Hospitalist

Seeking BE/BC Hospitalists to join our group in Montana’s premier, state-of-the-art medical center, which serves as the region’s tertiary referral center. Our seasoned team values work-life balance and collegiality. • Extremely flexible scheduling Billings Clinic is nationally • Generous salary with recognized for clinical yearly bonus excellence and is a proud member of the Mayo Clinic Care • Signing bonus Network. Located in Billings, • Student loan repayment Montana – this friendly college • No procedures required community is a great place to • Teaching opportunities raise a family near the majestic Rocky Mountains. Exciting • “America’s Best Town of 2016” outdoor recreation close to – Outside Magazine home. 300 days of sunshine! Contact: Rochelle Woods 1-888-554-5922 physicianrecruiter@ billingsclinic.org billingsclinic.com

Physicians You’re just one click away from your next job with the new SHM Career Center You’ve never had a more powerful ally in making your next career move. The new SHM Career Center is designed for busy doctors. Now you can: • Create job alerts • Quickly search for jobs on your smartphone • Save your jobs – works seamlessly! Create a candidate profile and get matched to your ideal job Find your next job today. Visit www.shmcareers.org

X To learn more, visit www.the-hospitalist.org and click on “Advertise” or contact Heather Gentile • 973.290.8259 • [email protected] or Linda Wilson • 973.290.8243 • [email protected]

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HOSPITALIST

The Division of Internal Medicine at Penn State Hershey Medical Center, The Pennsylvania State University College of Medicine, is accepting applications for HOSPITALIST positions. Successful candidates will hold a faculty appointment to Penn State College of Medicine and will be responsible for the care in patients at Penn State Hershey Medical Center. Individuals should have experience HOSPITALIST in hospital medicine and be comfortable managing patients in a sub- acute care setting. Hospitalists will be part of the post-acute A.O. Fox Memorial Hospital, an acute care community care program and will work in collaboration with advanced practice clinicians, residents, and staff. In addition, the candidate will hospital and affiliate of the Bassett Healthcare Network, is supervise physicians-in-training, both graduate and undergraduate level, as well as participate in other educational initiatives. The seeking a BC/BE Hospitalist to provide quality patient care. candidate will be encouraged to develop quality improvement projects in transitions of care and other scholarly pursuits around caring for this population. This opportunity has potential for growth into a leadership role as a medical director and/or other leadership This Hospitalist position is located in Oneonta, NY. It will roles. consist of a 7 on 7 off schedule with the option for other flexible scheduling. The unit consists of 53 bed med/surg Competitive salary and benefits among highly qualified, friendly colleagues foster networking opportunities. Relocation assistance, beds. Subspecialty Services are available in Cardiology, CME funds, Penn State University tuition discount for employees and dependents, LTD and Life insurance, and so much more! Cancer Care and Orthopedics. A fully integrated EMR Known for home of the Hershey chocolate bar, Hershey, PA is rich in history and offers a diverse culture. Our local neighborhoods system is in place. boast a reasonable cost of living whether you prefer a more suburban setting or thriving city rich in theater, arts, and culture. Hershey, Nestled in the foothills of the Catskill Mountains, the PA is home to the Hershey Bears hockey team and close to City of Oneonta is characterized as a friendly community the Harrisburg Senators baseball team. The Susquehanna -- one that is proud of its diversity, stability and beauty. River, various ski slopes and the Appalachian Trail are in our Successful candidates require the following: The City is home to two colleges, State University of New backyard, offering many outdoor activities for all seasons. • Medical degree - M.D., D.O. or foreign equivalent York at Oneonta and Hartwick College, a private liberal • Completion of an accredited Internal Medicine Residency program arts college. • Eligibility to acquire a license to practice in the Commonwealth of Pennsylvania For confi dential consideration, please contact: • Board eligible/certified in Internal Medicine • No J1 visa waiver sponsorships available Debra Ferrari, Medical Staff Recruitment Bassett Healthcare Network For further consideration, please send your CV to: One Atwell Road Brian McGillen, MD – Director, Hospital Medicine Cooperstown, NY, 13326 The Penn State Milton S. Hershey Medical Center is committed to affi rmative Penn State Milton S. Hershey Medical Center action, equal opportunity and the diversity of its workforce. Equal Opportunity c/o Heather Peffl ey, PHR FASPR – Physician Recruiter phone: 607-547-6982; fax: 607-547-3651 or email: Employer – Minorities/Women/Protected Veterans/Disabled. hpeffl [email protected] [email protected] or for more information visit our web-site at www.bassett.org.

ACADEMIC HOSPITALIST

UNIVERSITY OF MICHIGAN Hospitalist Position in Picturesque Bridgton, Maine: Bridgton Hospital, part of the Central Maine The University of Michigan, Division of General Medicine seeks BC/BE internists to join our expanding Academic Hospital Medical Family, seeks BE/BC Internist to join its Medicine Group. Duties include teaching, providing direct patient care, and involvement in quality improvement and patient well-established Hospitalist program. Candidates safety initiatives. There are opportunities to work on traditional general medicine services, in unique specialty concentrations may choose part-time (7-8 shifts/month) to full- (hematology/oncology, renal/transplant), as a full-time nocturnist, or in our newly developed medical observation unit. The time (15 shifts/month) position. Located 45 miles hospital medicine observation unit provides care for complex adult inpatients and incorporates mid-level providers as part of the medical team. Prior training or clinical experience at a major academic medical center is preferred. Research west of Portland, Bridgton Hospital is located in opportunities and hospitalist investigator positions are also available for qualified candidates. Successful candidates will the beautiful Lakes Region of Maine and boasts a receive a faculty appointment at the University of Michigan Medical School. Excellent benefits and compensation package wide array of outdoor activities including boating, with guaranteed salary plus incentive bonuses. Relocation support provided. kayaking, fishing, and skiing. LOAN FORGIVENESS PROGRAM: An educational loan forgiveness program provides up to $50,000 in loan forgiveness for Benefits include medical student loan assistance, qualifying educational loans. competitive salary, highly qualified colleagues and The University of Michigan is an equal opportunity/affirmative action employer and encourages applications from women and minorities. excellent quality of life. Send cover letter and CV to: To inquire please contact: For more information visit our website at Laurence McMahon, MD, MPH Scott Flanders, MD Chief, Division of General Medicine Director, Hospitalist Program www.bridgtonhospital.org 300 North Ingalls, Room NI7C27 Department of Internal Medicine Interested candidates should contact Ann Arbor, MI 48109-0429 734-647-2892 Julia Lauver, CMMC Physician Recruitment FAX: 734-936-8944 [email protected] 300 Main Street, Lewiston, ME 04240 [email protected] email: [email protected] Visit our website: http://www.med.umich.edu/intmed/genmed/programs/HospitalistProgram.htm call: 800/445-7431 fax: 207/755-5854

Expand your reach with an ad in Journal of Hospital Medicine—SHM’s clinical content journal For rates or to place an ad, contact Heather Gentile or Linda Wilson 973.290.8259 973.290.8243 [email protected] [email protected]

Earn a 7.5% discount when you advertise in both SHM publications.

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Helping people live the healthiest

lives possible. HOSPITAL MEDICINE AT LEHIGH VALLEY HEALTH NETWORK

Intermountain Healthcare has outpatient opportunities for Lehigh Valley Health Network (LVHN) is a nonprofit community hospital system in Internal Medicine and Hospitalists throughout Utah in all major cities. eastern Pennsylvania. The 800-bed main campus, pictured above, is located one INTERNAL MEDICINE HOSPITALIST hour north of Philadelphia and 90 minutes west of NYC. Within a 50-mile radius • Enjoy a 4 day work week • Reasonable patient load there are 6 hospital campuses and a growing primary care referral base. U.S. News • Loan repayment and signing bonus • Flexible work schedule • Stipend available for those still in training • Competitive salary, signing bonus & World Report has ranked LVHN among America’s Top Hospitals for 21 • Outpatient only with mental health integration • Pension, 401k match, • Pension, 401k match, and relocation and relocation consecutive years and currently has two of our hospital campuses ranked in the top 10 hospitals in the state. The network is seeking board certified/eligible IM or FM TOP REASONS TO CHOOSE UTAH: World-Class Year-Round • Skiing, Hiking, and Biking • 5 National Parks physicians for Hospitalist positions. We offer candidates a dedicated home-base 4 Distinct Seasons • Best State for Business • Endless Outdoor Recreation Opportunities campus with little or no travel between sites. Basic details about our hospital medicine program are listed below.

[email protected] • 800.888.3134 • PhysicianJobsIntermountain.org Unless otherwise specied, visa sponsorship not available x 7 on/ 7 off schedule x 2 weeks paid vacation x Competitive salary and benefits x 10 hour shifts x Sign-On bonus x Resident teaching x Retention bonus x x Relocation assistance Hospitalist/Nocturnist Opportunities APC support x nocturnist programin several locations x CME allowance Cambridge Health Alliance (CHA) is a well respected, nationally recognized and award-winning public healthcare system, which x No procedures x Moonlighting opportunities receives recognition for clinical and academic innovations. Our system is comprised of three campuses and an integrated network of x No ICU both primary and specialty care practices in Cambridge, Somerville x and Boston’s Metro North Region. CHA is a teaching affiliate of No forced OT both Harvard Medical School (HMS) and Tufts University School of Medicine and opportunities for teaching medical students and residents are plentiful. LVHN offers providers the strength of a large network, an integrated medical We are currently recruiting BC/BE Hospitalist/Nocturnist to join our division of approximately 20 physicians to cover inpatient staff with easy access to Department Chairs, tele-medicine to connect services at both our Cambridge and Everett campuses. This position has both day and night clinical responsibilities. Ideal candidates with campuses to services, 5 air ambulances for fast and efficient patient be FT (will consider PT), patient centered, posses excellent clinical/ transport and a platform to develop and grow your professional career. The communication skills and demonstrate a strong commitment to work with a multicultural, underserved patient population. Experience and communities served by LVHN include metropolitan-like cities, suburbs in the interest in performing procedures, as well as resident and medical student teaching is preferred. All of our Hospitalists/Nocturnist Pocono Mountains and rural communities with a moderate cost of living, hold academic appointments at Harvard Medical School. At fascinating history and small town charm. All of these areas are close – but CHA we offer a supportive and collegial environment, a strong infrastructure, a fully integrated electronic medical record system not too close -- to Philadelphia and NYC. (EPIC) and competitive salary/benefits package. Please send CV’s to Deanna Simolaris, Department of Physician Recruitment, Cambridge Health Alliance, 1493 Cambridge Street, Cambridge, MA 02139, via e-mail: [email protected], via Please call 484-862-3202 or send fax (617) 665-3553 or call (617) 665-3555. www.challiance.org We are an equal opportunity employer and all qualified applicants will CV to [email protected] receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability status, protected veteran status, or any other characteristic (No Visas) protected by law.

Physicians You’re just one click away from your next job with the new SHM Career Center You’ve never had a more powerful ally in making your next career move. The new SHM Career Center is designed for busy doctors. Now you can: • Create job alerts • Quickly search for jobs on your smartphone • Save your jobs – works seamlessly! Create a candidate profile and get matched to your ideal job Find your next job today. Visit www.shmcareers.org

X To learn more, visit www.the-hospitalist.org and click on “Advertise” or contact Heather Gentile • 973.290.8259 • [email protected] or Linda Wilson • 973.290.8243 • [email protected]

www.the-hospitalist.org I +"/6"3:

I 5)& )041*5"-*45  Make your next smart move. Visit www.shmcareers.org

JOIN A LEADER IN HOSPITAL MEDICINE A job designed for a career, not just a stepping stone.

INSPIRE greatness At Mercy Medical Group, a service of Dignity Health Medical Foundation, we lead by example. By always striving to give our personal best—and encouraging our patients and colleagues to do the same—we’re able to achieve and do more than we ever imagined. If you’re ready to inspire greatness in yourself and others, join us today. HOSPITALISTS - Sacramento, CA Full-time and part-time openings are available, as are opportunities for Nocturnists. At our large multi-specialty practice with approximately - -RLQRXUJURZLQJWHDPRISK\VLFLDQV:HRIIHUDYDULHW\RIWHDFKLQJDQGQRQ WHDFKLQJLQSDWLHQWPHGLFDO 400 providers, we strive to offer our patients a full scope of healthcare DQGFRQVXOWDWLYHVHUYLFHV3DWLHQWVHUYLFHVDW7KH2KLR6WDWH8QLYHUVLW\:H[QHU0HGLFDO&HQWHU-DPHV&DQFHU services throughout the Sacramento area. Our award-winning &HQWHU5LFKDUG05RVV+HDUW+RVSLWDO8QLYHUVLW\+RVSLWDO(DVWDQG1DWLRQZLGH&KLOGUHQ¶V+RVSLWDOV 0HG-3HGV  Hospitalist program has around 70 providers and currently serves 4 major hospitals in the area.

Sacramento offers a wide variety of activities to enjoy, including fine }7HDFKLQJUHVHDUFKDQG4,RSSRUWXQLWLHV})XOOSDUWWLPHDQG1RFWXUQLVWSRVLWLRQV})OH[LEOHVFKHGXOH}5HORFDWLRQDOORZDQFH dining, shopping, biking, boating, river rafting, skiing and cultural events. 6XFFHVVIXOFDQGLGDWHVUHFHLYHDIDFXOW\DSSRLQWPHQWDW7KH2KLR6WDWH8QLYHUVLW\&ROOHJHRI0HGLFLQHAcademic rank and salary commensurate with experience. Our physicians utilize leading edge technology, including EMR, and enjoy a comprehensive, excellent compensation and benefits package in a collegial, supportive environment. We are interviewing competitive applicants now! Forward your letter of interest and CV: For more information, please contact: Physician Recruitment KWWS*RRVXHGXKRVSLWDOPHGLFLQH Phone: 888-599-7787 | Email: [email protected] KRVSLWDOPHGLFLQH#RVXPFHGX www.mymercymedgroup.org - www.dignityhealth.org/physician-careers   These are not J1 opportunities. We are an Equal Opportunity/Affirmative Action Employer, Qualified women, minorities, Vietnam-era and disabled Veterans, and individuals with disabilities are encouraged to apply.7KLVLVQRWD-RSSRUWXQLW\

The University of Toledo Department of Internal Medicine, Toledo, Ohio, HOSPITALISTS, NOCTURNISTS & SITE LEAD Johnston Memorial Hospital, located in Historic Abingdon, Virginia, Requirements: MD/DO, Hospitalist/Nocturnist. Seeking is currently seeking Full Time BE/BC, Day Shi Hospitalists, Nocturnist � and Site Lead to join their team. ese are Full Time positions with the Assistant Professor in Hospital Medicine. Du es include following incentives: � � medical care of acutely ill pa ents in a hospital se ng, ● Hospital Employed (earning potential up to $300k per year) inpa�ent hospital instruc�on and teaching of house officers ● Day Shi (7 days on -7 days o‹) (7am - 7pm) ● Nocturnist (7 days on - 7 days o‹) (7pm - 7am) and medical students, and quality leadership enhancement ● Site Lead (12hr clinical shifts 24hr admin - per month) � ● Competitive Annual Salary related to inpa ent care. A successful candidate will present ● Performance Bonus & Production Bonus at and par�cipate in resident lectures, resident conferences ● Excellent Bene•ts ● Generous Sign On Bonus and Grand Rounds. Will precept medical students on hospital ● Relocation and Educational Loan Assistance ● Teaching and Faculty opportunities with the JMH FM/IM Residency inpa�ent service, and will provide full‐�me inpa�ent coverage. Training Programs ● Critical Care Physician Coverage in CCU/PCU

Please forward le�ers of interest along with a Please view our online job tour: copy of curriculum vitae to: www.mshajobtour.com/jmh Please Contact: The University of Toledo Health Science Campus, Tina McLaughlin, CMSR, Johnston Memorial Hospital Department of Medicine, MS 1186, Toledo, Ohio 43614. Oce (276) 258-4580, [email protected] Telephone (419) 383‐5149, Email: [email protected] The University of Toledo is an Affirma�ve Ac�on/Equal Opportunity Employer.

Now you have many more digital options available for your recruiting

• The country’s largest, 100%-validated U.S. physician database—the only one that’s BPA audited • Candidates who are guaranteed to be licensed, practicing U.S. physicians • Banner & native ads in the SHM member e-newsletter • Customized searches to match your job to the exact physician profile you want

X To learn more, visit www.the-hospitalist.org and click on “Advertise” or contact Heather Gentile • 973.290.8259 • [email protected] or Linda Wilson • 973.290.8243 • [email protected]

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I www.the-hospitalist.org Make your next smart move. Visit www.shmcareers.org

e Practice You’ve Always Wanted in the Hometown  Physician owned and managed You’ve Always  Enjoy an outstanding employment package Dreamed About  Bask in the beauty of a mild climate, stunning lakes and Hospitalist positions pristine national forests are now available.

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

NORTHERN ARIZONA NAzH HOSPITALISTS

NazHospitalists.com  Prescott, Arizona Family life. Amazing HM career. Classified Advertising You can have both. FIND THE PERFECT FIT! For more information on placing your classified advertisement in the next available issue, contact: Heather Gentile • 973.290.8259 [email protected] or Linda Wilson • 973.290.8243 [email protected]

+263,7$/,676 12&7851,676 US Acute Care Solutions values family. *5($7(567/28,6$5($ As HM and EM physician owners and partners, we are one family, united in our 0HUF\&OLQLFis seeking +RVSLWDOLVWVDQG1RFWXUQLVWV passion to provide the best integrated acute care for our patients. Our support to join established Hospitalist teams at various hospital extends far beyond our clinical settings. locations throughout the *UHDWHU6W/RXLVDUHD When a clinician in our group has a child we rally around them with our incredible 3RVLWLRQV2IIHU ground-breaking Paid Parental Leave x Competitive base salary, quarterly bonus and incentives x Package to ensure they receive the time Attractive block schedule and financial support they need to x System-wide EPIC EMR continue excelling in their careers. x Sponsorship of H1B Visa’s At USACS, we’re living life to x Comprehensive benefits including health, dental, vacation and CME the fullest, together. x Relocation assistance and professional liability coverage

For more information, please contact:

-RDQ+XPSKULHV_0DQDJHU3K\VLFLDQ5HFUXLWPHQW

[email protected]

314-364-3840 | mercy.net

Learn more. Visit usacs.com/family Founded by ERGENTUS, APEX, TBEP, MEP, EPPH and EMP or call us at 1-844-863-6797. [email protected]

Physicians You’re just one click away from your next job with the new SHM Career Center You’ve never had a more powerful ally in making your next career move. The new SHM Career Center is designed for busy doctors. Now you can: • Create job alerts • Quickly search for jobs on your smartphone • Save your jobs – works seamlessly! Create a candidate profile and get matched to your ideal job Find your next job today. Visit www.shmcareers.org

X To learn more, visit www.the-hospitalist.org and click on “Advertise” or contact Heather Gentile • 973.290.8259 • [email protected] or Linda Wilson • 973.290.8243 • [email protected]

www.the-hospitalist.org I +"/6"3:

I 5)& )041*5"-*45  Make your next smart move. Visit www.shmcareers.org

Hospitalist- ACADEMIC NOCTURNIST HOSPITALIST Nocturnist

The Division of General Internal Medicine at Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine (Hershey, PA) is seeking a BC/BE Internal Medicine NOCTURNIST HOSPITALIST to join our highly regarded team. Successful candidates will hold a faculty appointment to Penn State College of Medicine and will be White Plains Hospital has a reputation for both clinical excellence and responsible for the care in patients at Hershey Medical Center. Individuals should have experience in hospital medicine outstanding personalized care. The state-of-the-art hospital is a twelve- and be comfortable managing patients in a sub-acute care setting. time winner of the Consumer Choice Award, an honor given to the nation’s top hospitals by the National Research Corporation, and received Magnet® Our Nocturnists are a part of the Hospital Medicine program and will work in collaboration with advanced practice designation in 2012 from the American Nurses Credentialing Center (ANCC). It is also the only hospital in New York State to be included by Soliant Health clinicians and residents. Primary focus will be on overnight hospital admission for patients to the Internal Medicine in its 20 Most Beautiful Hospitals in the United States for 2016. service. Supervisory responsibilities also exist for bedside procedures, and proficiency in central line placement, Our expanding Adult Hospitalist Program is seeking exceptional candidates paracentesis, arthrocentesis, and lumbar puncture is required. The position also supervises overnight Code Blue and interested in Full Time Night positions. Candidates must be BC/BE in Internal Medicine and have the ability to work well in a professional, collegial Adult Rapid Response Team calls. This position directly supervises medical residents and provides for teaching atmosphere. opportunity as well. • Ranked by CNN Money as one of the best cities to live in • Only 25 minutes north of New York City Competitive salary and benefits among highly qualified, friendly colleagues foster networking opportunities. Excellent • Hospitalists are employed by the hospital/ICU covered by Intensivists schools, affordable cost of living, great family-oriented lifestyle with a multitude of outdoor activities year-round. • Competitive salary including employment and incentive bonus Relocation assistance, CME funds, Penn State University tuition discount for employees and dependents, LTD and programs, paid vacation & paid CME • Comprehensive benefits include: health/dental/vision, paid Life insurance, and so much more! malpractice, 403(b)plan • State-of the-art electronic medical records system Appropriate candidates must possess an MD, DO, or foreign equivalent; be Board Certified in Internal Medicine and have or If you are interested in joining a professional and dynamic team of 30 be able to acquire a license to practice in the Commonwealth of Pennsylvania. Qualified applicants should upload a letter of Hospitalists in an award winning facility, please send your CV to: interest and CV at: http://tinyurl.com/j29p3fz Ref Job ID#4524 Attn: David Bigham, H.R. Director E-mail: [email protected] For additional information, please contact: White Plains Hospital, 41 East Post Road, White Plains, NY 10601 Fax: 914-681-2590 Brian Mc Gillen, MD — Director, Hospitalist Medicine

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

Innovative Nocturnist Opportunities in Chicago’s Northern Suburbs NorthShore University HealthSystem, Division of Hospital Medi- NorthShore’s Nocturnist opportunities offer many advantages cine, is currently seeking exceptional BC/BE Internal Medicine including competitive compensation, comprehensive benefits, physicians for Nocturnist and day/night hybrid opportunities flexible scheduling to accommodate various lifestyles, and a solid across four hospitals located in Evanston, Glenbrook, Highland platform of support that allows physicians to focus on patient Park, and Skokie serving the greater North Shore and Northern care. As the principal academic affiliate of the Pritzker School of Illinois communities. NorthShore has created an inventive Medicine at The University of Chicago, academic is available to To advertise in e Hospitalist or new Nocturnist model with 25% fewer hours, shorter qualified candidates. shifts, and competitive salary to minimize burnout and e Journal of Hospitalist Medicine NorthShore’s four award-winning hospitals offer advanced preserve work/life balance. Take advantage of this opportu- technology, ideal locations, leadership in medicine, and a highly nity to join a comprehensive, fully integrated healthcare delivery trained support staff. This is an excellent opportunity to provide system committed to its academic mission, EMR analytics, and quality patient care as part of a highly successful organization Contact: an exceptional patient experience. striving to preserve and improve human life. Heather Gentile • 973.290.8259 [email protected] Qualified candidates should submit their CV to: Kimberly Kitchell, Physician Talent Management Specialist or 9977 Woods Drive, Skokie, IL 60077 Email: [email protected] • Phone: (847) 663-8145 Linda Wilson • 973.290.8243 [email protected]

EOE: Race/Color/Religion/Sex/National Origin/Protected Veteran/Disability, VEVRRA Federal Contractor

Physicians You’re just one click away from your next job with the new SHM Career Center You’ve never had a more powerful ally in making your next career move. The new SHM Career Center is designed for busy doctors. Now you can: • Create job alerts • Quickly search for jobs on your smartphone • Save your jobs – works seamlessly! Create a candidate profile and get matched to your ideal job Find your next job today. Visit www.shmcareers.org

X To learn more, visit www.the-hospitalist.org and click on “Advertise” or contact Heather Gentile • 973.290.8259 • [email protected] or Linda Wilson • 973.290.8243 • [email protected]

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I www.the-hospitalist.org PRESIDENT’S DESK I By Brian Harte, MD, SFHM Embrace change as a hospitalist leader Tales from an insightful dive into SHM leadership training

e work in complex environments Wand in a flawed and rapidly chang- ing health care system. Caregiv- ers, patients, and communities will be led through this complexity by those who embrace change. Last October, I had the

privilege of attending and facilitating the Thinkstock SHM Leadership Academy in Orlando, which allowed me the opportunity to meet a group of people who embrace change, exercises, the group was quiet, uncertain, welcome to join us Scottsdale, Ariz., later including the benefits and challenges that tentative. I was struck both by how early this year. Learn more about the program at often accompany it. these individuals were in their development www.shmleadershipacademy.org. Dr. Harte is a practicing SHM Board member Jeff Glasheen, MD, and by how so much of what is happening At Leadership Academy and beyond, I hospitalist, president of the SFHM, taught one of the first lessons at today in hospitals and health care is depend- implore hospitalists to look for opportuni- Society of Hospital Medicine, Leadership Academy, focusing on the ent upon the development and success of ties to change during this time of New Year’s and president of Hillcrest importance of meaningful, difficult change. individuals like these who are enthusiastic resolutions and to take the opposite posture Hospital in Mayfield Heights, With comparisons to companies that have and talented but young and overwhelmed. and want to change – change how we think, Ohio, part of the Cleveland Clinic embraced change, like Apple, and some that I believe that successful hospitalists are, act, and respond; change our roles to take Health System. He is associate have not, like Sears, Jeff summed up how through experience, training, and nature, on new, uncomfortable responsibilities; and professor of medicine at the complacency with “good” and a reluctance rapid assimilators into their environments. change how we view change itself. Cleveland Clinic Lerner College to tackle the difficulty of change keeps By the third day, the dynamic at my table We will be better for it both personally of Medicine in Cleveland. organizations – and people – from becom- had gone from tentative and uncertain to and professionally, and we will stand out as ing great. much more confident and assertive. To role models for our colleagues, coworkers, “Good is the enemy of great,” Jeff experience this transformation in person and hospitalists who follow in our foot- preached. at SHM’s Leadership Academy, you are steps. He largely focused on hospitalists leading organizational change, but the concepts can apply to personal change, too. He explained that “people generally want things to be different, but they don’t want to change.”

At Leadership Academy Leaders in training Ten emerging hospitalist leaders sat at my and beyond, I implore table, soaking in the message. Several of them, like me 8 years ago, had the respon- Connecting practices to hospitalists to look for sibilities of leadership unexpectedly thrust opportunities to change upon them. Some carried with them the EMERGING TRENDS. heavy expectations of their colleagues or during this time of New hospital administration (or both) that by We’re taking the mal out of malpractice insurance. being elevated into a role such as medical In an ever-evolving healthcare environment, we director, they would abruptly be able to stay on top of the latest risks, regulations, and Year’s resolutions and advancements. From digital health innovations to make improvements in patient care and new models of care and everything in between, to take the opposite hospital operations. They had accepted the we keep you covered. And it’s more than a trend. challenge to change – to move out of purely It’s our vision for delivering malpractice insurance posture and want to clinical roles and take on new ones in lead- without the mal. Join us at thedoctors.com ership despite having little or no experi- change – change how ence. Doing so, they gingerly but willingly we think, act, and re- were following in the footsteps of leaders before them, growing their skills, improv- spond; change our roles ing their hospitals, and laying a path for future leaders to follow. to take on new, uncom- A few weeks prior, I had taken a new leadership position myself. The Cleveland fortable responsibilities; Clinic recently acquired a hospital and health system in Akron, Ohio, about 40 and change how we view miles away from the city. I assumed the role of president of this acquisition, embracing change itself. the complex challenge of leading the process of integrating two health systems. After 3 years overseeing a different hospital in the health system, I finally felt I had developed the people, processes, and culture that I had been striving to build. But like the young leaders at Leadership Academy, I had the opportunity to change, grow, develop, take on new risk, and become a stronger leader in this new role. A significant part of the experience of the Leadership Academy involves table exercises. For the first few

www.the-hospitalist.org I JANUARY 2017 I THE HOSPITALIST 29 EDITOR’S DESK I By Danielle Scheurer, MD, MSCR, SFHM Have you Googled yourself lately? With a majority of patients relying on physician ratings, hospitalists might consider countermeasures

he online rating business is prolifer- tisements and turns a sizable profit every care systems in the past few years primarily Tating in the medical industry. This year. Other profitable health care rating to take control of the conversation and to should really come as no surprise as sites include Healthgrades, Yelp, Zocdoc, not cede patient decision making to third- health care is a service industry and online and WebMD. party sites. ratings have long been a staple in most When I Google my own name, for exam- My health care system proposed roll- other service industries. It has become ple, Vitals.com is the first ratings website that ing out a similar online rating system, routine practice for most of us to search appears in the search results. The first pop-up and it was met with great skepticism from such online reviews when seeking a pair of asks you to rate me and then it takes you to many physicians. There were two primary shoes, a toaster, or a restaurant; we almost a site with all sorts of facts about me (most concerns: can’t help but scour these sites to help us of which are notably inaccurate . If I had any • They felt it was “tacky” and that the make the best decision possible. online ratings (which I do not currently), profession of medicine should not be Dr. Scheurer is a Many of these reviews come in quantita- you would then see my star ratings and any relegated to oversimplified service ratings. hospitalist and chief tive and qualitative forms, for example, stars comments. • They worried that they would feel pres- quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected]. Vitals.com

Figure 1. Physicianwiki or numerical ratings, along with qualita- 5.000 tive comments. Of course, when seeking 4.875 4.750 out products and services, these ratings are 4.625 not usually the sole mechanism that we 4.500 use to make decisions. For example, with 4.375 the toaster analogy, I would not only be 4.250 4.125 influenced by the reviews but also by the 4.000 cost and the accessibility of the toaster (for 3.875 example, when I can get it shipped or if it 3.750 3.625 is available in a nearby store). 3.500 Not dissimilarly, patients these days seek 3.375 care and make decisions by using a variety 3.250 of inputs, including: 3.125 • Anticipated cost (is the physician or prac-

Emergency Office Staff Waiting time Explanation Answers Time spent http://www.physicianwiki.com/dr-danielle-b-scheurer-md-internal-medicine tice in or out of network?). • Availability or access to the service (loca- tion of the practice and how long it will The second rating site that comes up for sured to please the patient rather than take to be seen). me via Google search is PhysicianWiki. “do the right thing” for the patient. For • How good the services and care will be com. There is a whole host of information example, they would be less likely to give when they get there. on me (most of which is accurate), along difficult advice (such as lose weight or A study in JAMA found the top two with a set of personal ratings, including stop smoking) or to resist prescribing factors influencing the selection of physi- my office, my staff, and my waiting times medications that they deemed unneces- cians were whether they accept a patient’s (which, of course, do not make any sense sary or frankly dangerous (for example, insurance and whether their location is given I am a hospitalist!). It is unclear antibiotics or narcotics). convenient.1 But the study also found that how those ratings were generated or what Although these are valid concerns, it is 59% of American adults considered online volume of responses they represent. hard to ignore the proliferation and traffic ratings “somewhat important” or “very Because of such limitations with the of these online websites. For you and your important” when choosing physicians. online rating business for physicians, some team, I would recommend taking a look at That same article found that, for those health care systems have tried to “take what is online about the members of your who used online physician ratings, about control of the conversation” by posting group and thinking about online strategies one-third had selected a physician based their own internally collected quantitative to take control of the conversation. on good ratings, and about one-third had and qualitative feedback from patients. The I don’t think the controversy over online avoided a physician based on poor ratings. University of Utah was one of the first in physician ratings will wane anytime soon, So patients do seem to be paying attention the nation to create its own internal site but there is no doubt that they are profit- to these sites and seeking or avoiding care for star ratings and comments.2 What you able for companies and are therefore highly based on what information they find. see on its site is detailed information about likely to continue to multiply. Based on that evidence, it is not surpris- the physicians (clinical profile, academic ing that so many physician rating sites profile, education, contact information, References have sprung up; not only is there a market etc.), their patient ratings on nine differ- 1. Hanauer DA, Zheng K, Singer DC, Gebremariam A, Davis MM. Public awareness, perception, and use of online demand for the availability of this informa- ent questions (displayed as star ratings), the physician rating sites. JAMA. 2014;311(7):734-735. tion, the rating sites are also profitable for number of total ratings, and a line listing of 2. A to Z provider listing: find a U of U Health Care physician the host companies. Vitals.com, for exam- patient comments (ordered by date). Such by last name. University of Utah website. Available at http:// ple, makes most of its revenue from adver- sites have proliferated among many health healthcare.utah.edu/fad. Accessed Nov. 16, 2016.

30 THE HOSPITALIST I JANUARY 2017 I www.the-hospitalist.org PRACTICE MANAGEMENT I By John Nelson, MD, MHM Effective hospitalist roles for NPs, PAs Single-site study offers success story, isn’t one-size-fits-all solution

JOHN NELSON, MD, MHM Notable study  ndings regarding the training background of the I think the main value of this study is in APCs they hire; he suspects an identical ’m often asked about effective roles for showing that the expanded PA group had study with NPs rather than PAs in each nurseI practitioners (NPs) and physi- rates of readmission, inpatient mortal- hospitalist group would probably yield cian assistants (PAs), collectively ity, length of stay, and consultant use that very similar results. I see this the same way. known as advanced practice clinicians weren’t statistically different from the Although there are differences in back- (APCs). My first response is always the conventional group. ground and training between NPs and PAs, same: They have much to contribute and The workloads and years of experience I think personal traits like years of experi- can be effective members of hospitalist of doctors and PAs in each group were ence in various health care settings and the groups. Most hospital medicine groups similar. And while there were some differ- ability to work efficiently are more impor- Dr. Nelson has been a (HMGs) should think about having ences in the patients each group cared for, tant than training background. practicing hospitalist since them in their staffing mix if they don’t they seem unlikely to have a significant 1988. He is co-founder already. influence on outcomes. Clearly, there are A practical approach and past president of SHM Yet despite all that NPs/PAs can offer, my many unmeasured variables (e.g., culture, Any group who thinks this study is evidence and principal in Nelson experience is that many (even most) hospi- morale, and leadership) in each group that adding more APCs and having them Flores Hospital Medicine talist groups fail to develop roles that opti- that could have influenced the outcomes, manage a higher number of patients rela- Consultants. He is co- mize their APCs’ skills. so this one study at one hospital doesn’t tively independently will go well in any director for SHM’s “Best An October 2016 study in the Journal of provide a definitive answer about appro- setting is mistaken. But it does offer a story Practices in Managing a Clinical Outcomes Management adds addi- Hospital Medicine Program” tional data to help think about this issue. course. Write to him at john. You may have seen the study mentioned [email protected]. in several news articles and blogs. Most Any group who thinks this study is evidence that adding summarized the study along the lines of “using high levels of PA staffing results in more APCs and having them manage a higher number of lower hospital costs per case.” Framing it this way is awfully misleading, so I’ll go a patients relatively independently will go well in any setting little deeper here. is mistaken. But it does offer a story of one place where, Study context The study, “A Comparison of Conven- with careful planning and execution, it went OK. tional and Expanded Physician Assistant Hospitalist Staffing Models at a Commu- nity Hospital,” is a retrospective analysis of performance measures from two hospitalist priate APC staffing levels. However, it of one place where, with careful planning groups at Anne Arundel Medical Center didn’t uncover big differences in the meas- and execution, it went OK. (AAMC) in Annapolis, Md.1 One HMG ured outcomes. In my view, the real take-home message is employed by the hospital. The other, And this study did show that higher levels is to think carefully to ensure any APCs in called MDICS, is a private company that of PA staffing were associated with lower your group have professionally satisfying contracts with AAMC as well as approxi- hospital charges per case. Although the roles that position them to contribute effec- mately 13 other hospitals and 40 rehabili- difference was a modest 3%, it was statisti- tively. While common, I think configuring tation facilities. Tim Capstack, MD, is the cally significant (P less than .001). I’m skep- APCs and physicians as rounding dyads AAMC medical director for MDICS and tical there is causation here; this more likely often ends up underperforming and not lead author of the study (representing a is just correlation. working out well because of inefficiency. potential conflict of interest acknowledged It would be great to see a larger study of When well executed, as is apparently the in the article). Barry Meisenberg, MD, is this. case in this study, it can be fine. But my a coauthor, a hospitalist in the AAMC- experience is that positioning APCs to employed group, and chair for quality Information applications assume primary responsibility for some clin- improvement and health care systems So does this study support the idea that ical activities, such as covering the observa- research at AAMC. HMGs can or should increase APC staffing tion unit or serving as an evening admitter/ Tim told me by phone that both groups and workload significantly to realize lower cross-cover provider (all with appropriate have practiced at AAMC for more than hospital cost per case and not harm patient physician collaboration and backup), more 10 years and enjoy a collegial relationship. outcomes? Not so fast! reliably turns out well. Both groups employ PAs and pair them This study compared only two hospital- with a single physician in a dyad arrange- ist groups at one hospital. It’s probably not Reference ment each day. Tim’s MDICS group, very generalizable. 1. Capstack TM, Seguija C, Vollono LM, Moser JD, Meisen- berg BR, Michtalik HJ. A comparison of conventional the “expanded PA” group, staffs each And as described in the paper, and and expanded physician assistant hospitalist staffing day shift with three physicians and three stressed by Tim talking with me by phone, models at a community hospital. J Clin Outcomes Manag. PAs, compared with the nine physicians the outcomes of their expanded PA model 2016;23(10):455-61. and two PAs in the hospital-employed likely have a lot to do with their very care- “conventional” group. The MDICS PAs ful recruiting and screening of experienced are responsible for more patients each day PAs before hiring them, not to mention a than their conventional-group counter- lengthy and deliberate on-boarding process parts and, during the January 2012 to July (summarized in the article) to support their 2013 study period, averaged 14.2 patients ability to perform well. Groups that are not versus 8.3, respectively. as thoughtful and deliberate in how they CHECK OUT MORE Over the course of the study, PAs in the hire and position APCs to contribute to the expanded PA group saw and billed 36% of practice may not perform as well. of Practice Management patient visits independently, compared with Why study only PAs? What about NPs? at the-hospitalist.org. 5.9% for the conventional group. Tim told me that his group is agnostic

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