June 2019 INNOVATIONS KEY CLINICAL QUESTION IN THE LITERATURE Volumeolume 23 No. 6 Reducing adverse Adjuvant corticosteroids MRSA p15 drug reactions p18 in CAP p20 decolonization

Following the path of leadership VA Hospitalist Matthew Tuck

By Larry Beresford

or Matthew Tuck, MD, MEd, FACP, associate section chief for hospital medicine at the FVeterans Affairs Medical Center (VAMC) in Washington, leadership is something that hospitalists can and should be learning at every opportunity. Some of the best insights about effective leadership, teamwork, and process improvement come from the business world and have been slower to infiltrate into hospital settings and hospitalist groups, he says. But Dr. Tuck has tried to take advantage of numerous opportunities for leadership development in his own career. He has been a hospitalist since 2010 and is part of a group of 13 physicians, all of whom carry clinical, teaching, and research responsibilities while pursuing a variety of education, quality improvement, and performance im- provement topics. “My chair has been generous about giving me time to do teaching and research and to pursue opportunities for career development,” he said. The Washington VAMC works with four af- Dr. Matthew Tuck filiate medical schools in the area, and ANDREW J. WHITE/WASHINGTON DC VA MEDICAL CENTER its six daily hospital medicine services are all 100% teaching services with as- signed residents and interns. Dr. Tuck divides his professional time roughly one-third each among clinical ® Continued on page 10 the-hospitalist.org

SURVEY INSIGHTS HOSPITALIST INSIGHTS Khuong Vuong, Jordan Messler,

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Are hospitalists being Pay heed to a warning song Lebanon Jct. KY Jct. Lebanon Denville, NJ 07834-3000 NJ Denville,

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Focus on science, PHYSICIAN EDITOR THE SOCIETY OF HOSPITAL MEDICINE Danielle B. Scheurer, MD, SFHM, MSCR; Phone: 800-843-3360 [email protected] Fax: 267-702-2690 PEDIATRIC EDITOR Website: www.HospitalMedicine.org not format Laurence Wellikson, MD, MHM, CEO Weijen Chang, MD, FACP, SFHM [email protected] Vice President of Marketing & Communications How JHM is improving the author experience COORDINATING EDITORS Lisa Zoks Dennis Chang, MD [email protected] THE FUTURE HOSPITALIST dening our peer reviewers so we ask Marketing Communications Manager By Samir S. Shah, MD, MSCE, Jonathan Pell, MD Brett Radler MHM them to review only manuscripts KEY CLINICAL GUIDELINES [email protected] that we are seriously considering CONTRIBUTING WRITERS SHM BOARD OF DIRECTORS any authors have experi- for publication. Second, we want to Larry Beresford; Suzanne Bopp; Ted President enced the frustration of ensure that we’re being respectful of Bosworth; Andrew D. Bowser; Weijen Chang, Christopher Frost, MD, SFHM MD, SFHM, FAAP; Jennifer K. Chen, MD; President-Elect formatting a manuscript our authors’ time. If we are unlikely Ngozi Eboh, MD; Leslie Flores, MHA, SFHM; Danielle Scheurer, MD, MSCR, SFHM for submission to a med- to publish a manuscript based on Alicia Gallegos; Leif Hass, MD; George Treasurer Mical journal. The process is time con- lower priority scores assigned by Hoke, MD; Nageshwar Jonnalagadda, MD, Tracy Cardin, ACNP-BC, SFHM Secretary suming and each journal has different me, as editor-in-chief, or other jour- MPH, FHM; Anika Kumar, MD, FAAP; Gene Lambert, MD, MBA, FACP; Farrin A. Manian, Rachel Thompson, MD, MPH, SFHM Immediate Past President requirements. This means that, if you nal editors, we don’t want to subject MD, MPH; Sarah Marsicek, MD; Venkatrao Nasim Afsar, MD, MBA, SFHM decide to submit your manuscript to your manuscript to a lengthy peer Medarametla, MD, SFHM, FACP; Jordan Board of Directors one journal and later decide that an- review, but would rather return the Messler, MD, SFHM; Bahnsen Miller, MD; Steven B. Deitelzweig, MD, MMM, SFHM other journal is a better fit, you may manuscript to you quickly for time- Kari Oakes; M. Alexander Otto; Christopher Bryce Gartland, MD, FHM Palmer; Andrew S. Parsons, MD, MPH; Jake spend an hour ly submission elsewhere. Flora Kisuule, MD, MPH, SFHM Remaly; Adith Sekaran, MD; Samir S. Shah, Kris Rehm, MD, SFHM (or several hours) Here are data that support our MD, MSCE, MHM; Hugo Torres, MD, MPH; Mark W. Shen, MD, SFHM reformatting to timely decision making: Gregory Twachtman; Amar Vedamurthy, Jerome C. Siy, MD, SFHM meet the new • 1.3 days = our average time from MBBS, MS; Khuong Vuong, MD, FHM; Chad T. Whelan, MD, MHSA, FHM Amber Wright, MD; Catherine Wysocka, MD FRONTLINE MEDICAL journal’s unique manuscript submission to rejec- FRONTLINE MEDICAL COMMUNICATIONS ADVERTISING STAFF requirements. tion without formal peer review COMMUNICATIONS EDITORIAL STAFF VP/Group Publisher; Director, To allow authors (median, less than 1 day). Editor in Chief Mary Jo M. Dales FMC Society Partners to spend more • 23 days = our average time from Executive Editors Denise Fulton, Mark Branca Kathy Scarbeck National Account Managers time on what mat- manuscript submission to first Editor Richard Pizzi Valerie Bednarz, 973-206-8954 ters to them, we’re Dr. Shah decision for manuscripts sent for Creative Director Louise A. Koenig cell 973-907-0230 [email protected] pleased to intro- peer review. 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We pro- ded in the main document file or duce press releases and distribute THE HOSPITALIST is the official newspaper of the THE HOSPITALIST (ISSN 1553-085X) is published uploaded individually, depending on those to media outlets in partner- Society of Hospital Medicine, reporting on issues monthly for the Society of Hospital Medicine by and trends in hospital medicine. THE HOSPITALIST Frontline Medical Communications Inc., 7 Century your preference. Funding and disclo- ship with SHM. We also leverage reaches more than 35,000 hospitalists, physician Drive, Suite 302, Parsippany, NJ 07054-4609. Print sures should be included on the title social media to promote your article assistants, nurse practitioners, medical residents, and subscriptions are free for Society of Hospital Medi- health care administrators interested in the practice cine members. 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We do pital Medical Center. He is the current The Hospitalist is a member. this for two reasons. First, we want editor-in-chief of the Journal of Hos- To learn more about SHM’s relationship with industry partners, visit www.hospitalmedicine.com/industry. to ensure that we’re not overbur- pital Medicine. June 2019 | 2 | The Hospitalist PRACTICE MANAGEMENT

Survey Insights Are hospitalists being more highly valued? An uptrend in financial support

By Khuong Vuong, MD, FHM The median amount of financial In addition, increasing productivity support per FTE provider (includ- can be challenging, a double-edged ince the inception of hospital ing nurse practitioners, physician sword that may further escalate medicine more than 2 de- assistants, and locum tenens) was burnout and turnover rates. The cades ago, the total number $134,300, which represents a 3.3% static productivity may portend that of hospitalists has rapidly decrease, com- it has leveled off or Sincreased to more than 60,000. The pared with the 2016 hit the ceiling in spite Society of Hospital Medicine’s State SoHM Report. For of ongoing efforts to of Hospital Medicine Report (SoHM), the first time, the improve efficacy. published biennially, captures new 2018 SoHM also In my view, the changes in our growing field and collected data on decision to invest in sheds light on current practice financial support per “work rela- hospitalists for their contributions trends. tive value unit” (wRVU) in addition and dedications should not be deter- Among its findings, the 2018 SoHM to support per FTE physician and mined based on a single metric such Report reassuringly reveals that support per FTE provider. HMGs as wRVUs per physician. Hospitalist financial support from hospitals to and their hospitals can use support work on quality improvements; pa- hospital medicine groups (HMGs) per wRVU data to evaluate the sup- tient safety; efficiency, from direct continues to climb, even in the set- port per unit of work, regardless of bedside patient care to nonclinical ting of rising health care costs and who (whether it is a physician, an efforts; teaching; research; involve- Dr. Vuong is a hospitalist at ongoing budget pressure. advanced practice provider, and/or ments in various committees; admin- HealthPartners Medical Group others) performed that work. istrative tasks; and leadership roles in St Paul, Minn., and an assis- The median amount of financial in improving health care systems are tant professor of medicine at the support per wRVU for HMGs serv- immeasurable. These are the reasons University of Minnesota. He is a “Hospitalists have a ing adults in 2018 was $41.92, with that most hospitals chose to adopt member of SHM’s Practice Analy- responsibility to prove academic HMGs reporting a higher the hospitalist model and continue sis Committee. that they are the right amount ($45.81) than nonacademic to support it. In fact, demand for HMGs ($41.28). It will be interesting hospitalists still outstrips supply, as group chosen to do the to track these numbers over time. evidenced by more than half of the work and help achieve One of the most intriguing find- hospital medicine groups with un- References ings from the SHM’s 2018 SoHM filled positions and an overall high Afsar N. Looking into the future and ,aking their hospital’s mission Report is that financial support has turnover rate per 2018 SoHM data. history. Hospitalist. 2019;23(1):31. and goals.” risen despite relatively flat profes- Although hospitalists are needed Beresford L. The state of hospital medicine in sional fee productivity (see Figure 1). for the value that they provide, they 2018. Hospitalist. 2019;23(1):1-11. Productivity, calculated as work rel- should not take the status quo for FitzGerald S. Not a time for modesty. Oct 2009. Retrieved from https://acphospitalist.org/ ative value units (wRVUs) per phy- granted. Instead, in return for the archives/2009/10/value.htm. The median amount of financial sician declined slightly from 4,252 in favorable financial support and in Watcher RM et al. Zero to 50,000 – The 20th support per full-time equivalent 2016 to 4,147 in 2018. appreciation of being valued, hospi- anniversary of the Hospitalist. N Eng J Med. (FTE) physician for HMGs serving There may be a few reasons why talists have a responsibility to prove 2016. 375(11):1009-11. adults was $176,658, according to the wRVUs per physician has remained that they are the right group chosen 2018 SoHM Report, which is up 12% relatively unchanged over the to do the work and help achieve from the 2016 median of $157,535. years. Many hospitals emphasize their hospital’s mission and goals. While there is no correlation be- quality of care above pro- tween group sizes and the amount vider productivity. The of financial support per FTE phy- volume-to-value shift in Figure 1. Trends in financial support and productivity, 2012-2018 sician, there are significant differ- theory serves as a means ences across regions, with HMGs in to reduce hospital-associ- Financial support Productivity (wRVUs) the Midwest garnering the highest ated complications, length $200,000 6,000 median support, at $193,121 per FTE of stay, and readmission physician. rates, thereby avoiding The report also reveals big differ- penalties and saving the $180,000 5,000 ences by employment model. For overall costs for the hospi- example, private multispecialty and tals in the long run. $160,000 4,000 primary care medical groups receive Hospitalists involved in much less financial support ($58,396 quality improvement proj- per FTE physician) than HMGs ects and other essential $140,000 3,000 employed by hospitals. This likely nonclinical work perform signifies that their main source of tasks that are rarely cap- $120,000 2,000 revenue is from professional service tured in the wRVU metric. fees. Regardless of the types of em- Improving patient experi- ployment models, past surveys have ence, one of the Triple Aim 0 0 MDedge News reported more than 95% of HMGs components, necessitates 2012 2014 2016 2018 2012 2014 2016 2018 receive support from their hospitals extra time and effort, to help cover expenses. which also are nonbillable. Source: Society of Hospital Medicine’s 2018 State of Hospital Medicine Report the-hospitalist.org | 3 | June 2019 PRACTICE MANAGEMENT

The Hospital Leader Why you should re-credential with Medicare as a hospitalist CMS needs a better database of hospitalist information

By Leslie Flores, MHA, SFHM ever that means). necessary overlap between services It doesn’t change how your claim provided by you and an internal n April 2017, the Centers for is processed or how much you get medicine or family physician to Medicare & Medicaid Services paid. So why bother going through the same patient on the same cal- implemented the new physician the laborious process of re-creden- endar day, you can make a better specialty code C6, specifically for tialing with CMS via PECOS just to argument that your services were Ihospitalists. There has been a lot of change your specialty code? Well, unique and complementary to confusion about what this means I believe there are several ways in (not duplicative of) the services of and some uncertainty about why cli- which the C6 specialty code pro- others if you are credentialed as a nicians should bother to use it. vides value – both to you and to the hospitalist. Some folks thought initially that specialty of hospital medicine. it was a new CPT code they could Ensure “apples to apples” use to bill hospitalist services, which Reduce concurrent care denials comparisons might recognize the increased First, it distinguishes you from a A second reason to re-credential as intensity of services hospitalists general internal medicine or general a hospitalist is to ensure that, when often provide to their hospitalized family medicine practitioner by rec- the CMS looks at the services you patients compared to many tradi- ognizing “hospitalist” as a distinct are providing and the CPT codes tional internal medicine and family specialty. This can be valuable from you are selecting, it is comparing medicine primary care physicians. a financial perspective because it you to an appropriate peer group for Others thought it was a code that may reduce the risk that claims for compliance purposes. was added to the Health Care Fi- your services might be denied be- The mix of CPT codes reported nancing Administration 1500 billing cause of “concurrent care” by anoth- by hospitalists in the SHM State of form somewhere to designate that er provider in the same specialty on Hospital Medicine Survey has his- Ms. Flores is a partner at Nelson the service was provided by a hos- the same calendar day. torically tilted toward higher-level Flores Hospital Medicine Consultants, pitalist. And it’s not just a general internist care than has the mix of CPT codes La Quinta, Calif. She serves on SHM’s Neither is true. The C6 physician or family medicine physician that reported by the CMS for internal Practice Analysis and Annual Meeting specialty code is one of a large num- you might run into concurrent care medicine or family medicine physi- Committees, and helps to coordinate ber of such codes used by physicians trouble with. I’ve seen situations cians. But last year when Medicare SHM’s bi-annual State of Hospital to designate their primary physician where doctors completed critical care released the utilization of evalua- Medicine Survey. specialty when they enroll with or cardiology fellowships but never tion and management services by Medicare via the Provider Enroll- got around to re-credentialing with specialty for calendar year 2017, CPT ment, Chain, and Ownership System Medicare in their new specialty, so utilization was shown separately for and its impact on the overall (PECOS) online enrollment system. their claims still showed up with an hospitalists for the first time! health care system will be signifi- It describes the unique type of med- “internal medicine” physician spe- The volume of services reported cantly enhanced by a more robust icine practiced by the enrolling phy- cialty code, resulting in denied “con- for physicians credentialed as hos- presence of physicians who have sician and is used by the CMS both current care” claims for either the pitalists was very small relative to identified themselves as hospital- for claims processing purposes and hospitalist or the specialist. the volume of inpatient services ists in the PECOS credentialing for “programmatic” purposes (what- While Medicare may still see un- provided by internal medicine and system. family medicine physicians, but the We care for the majority of distribution of inpatient admission, patients in most hospitals these Distribution of inpatient subsequent-visit CPT codes, 2017 subsequent visit, and discharge days, yet “hospitalists” billed only codes for hospitalists closely mir- 2,009,869 inpatient subsequent 99231 99232 99233 rored those reported by SHM in visits (CPT codes 99231, 99232, its 2018 State of Hospital Medicine and 99233) in 2017 compared to Report (see graphic). If you’re going 25,903,829 billed by internal medi- to be targeted in a RAC audit for the cine physicians and 4,678,111 billed SHM all adult high proportion of 99233s you bill, by family medicine physicians. And you want to be sure the CMS is look- regardless of what you think about ing at your performance compared using claims data as a proxy for CMS hospitalist to those who are truly your peers, health care services and quality, caring for patients of the same type it’s undeniably the best data set we CMS family and complexity. currently have. practice So, let’s work together to build a Improve CMS data used for bigger, better database of hospitalist EWS CMS internal research purposes information at the CMS. I urge you medicine Finally, the ability of academic hos- to go to your credentialing folks to- MD EDGE N pitalists and other health services day and find out how you can work 0 20% 40% 60% 80% 100% researchers to utilize Medicare with them to get yourself re-creden- claims data to better understand tialed in PECOS using the C6 “hospi- Source: 2018 State of Hospital Medicine Report the care provided by hospitalists talist” physician specialty. June 2019 | 4 | The Hospitalist Make some noise! Introducing 100% Paid Parental Leave for HM Clinicians.

At US Acute Care Solutions, our HM clinicians receive 100% Paid Parental Leave to ensure they get the time they need to be with their family and the financial support they deserve.Birth mothers receive eight weeks of paid time off at 100 percent pay, and another four weeks at 50 percent. Adoptive or surrogate parents, fathers, partners and spouses also get paid time off. As partners of one of the largest and fastest growing physician-owned groups in the nation, we are one family, united in our mission to care for our patients and each other.

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

HOSP_5.indd 1 5/16/2019 8:10:28 AM HM19 REVIEW Pediatric clinical conundrums Atypical symptoms and diagnoses

By Sarah Marsicek, MD, and manifestation of a common child- topical steroids and antibiotics, as talization. A bronchoscopy was per- Catherine Wysocka, MD hood disease. Stefan Mammele, MD, prescribed by ophthalmology. For formed and revealed a significantly a resident at Kapi’olani Medical Cen- this reason, she underwent further narrowed left bronchus at the carina Presenters: Yemisi Jones, MD; ter in Honolulu, and the University work-up and imaging. MRI of the and a blind pouch on the right with Mirna Giordano, MD of Hawaii, presented a case of an head and orbits revealed left maxil- notable pulsation of the walls. She Session title: Pediatric Clinical 11-year-old boy with a painful and lary sinus disease. She was treated underwent further imaging and Conundrums pruritic rash asso- with antibiotics was ultimately diagnosed with a ciated with mul- for acute left left pulmonary artery sling – a rare, Session summary: Dr. Giordano tiple 5- to 10-mm maxillary sinus- but potentially fatal anomaly that of Columbia University Irving tense bullae locat- itis and her hemo- can present with wheezing, stridor, Medical Center, New York, and ed on the patient’s lacria resolved and recurrent respiratory infections. Dr. Jones of Cincinnati Children’s bilateral lower within 24 hours. Patient underwent correction by Hospital Medical Center, moderated extremities with While the differ- cardiovascular surgery and has since the Pediatric Clinical Conundrums extension to the ential diagnosis been doing well. session at HM19. After reviewing trunk. The patient for hemolacria multiple submissions, they invited was also found to Dr. Marsicek Dr. Wysocka is broad, rarely Key takeaways for HM four trainees to present their have hematuria acute sinusitis • Bartonella is a common cause interesting cases. and proteinuria. The bullae drained has been reported as a cause. of fever of unknown origin, and both serosanguinous and purulent Recurrent bronchiolitis or some- should be considered in unusual Malignancy or infection? Jeremy material. Fluid culture grew group A thing more? Moira Black, MD, a presentations of febrile illnesses. Brown, MD, a resident at the Univer- Streptococcus and skin biopsy con- resident at Children’s Memorial • Bullae in IgA vasculitis are rare in sity of Louisville (Ky.), presented a firmed IgA vasculitis. Bullae are a Hermann in Houston, presented a children and do not have prognostic case of a 15-year-old male with right rare characteristic of Henoch Schön- case of a 7-month-old female with value, but streptococcal infection upper-quadrant abdominal pain lein pupura in children, but are a history of recurrent admissions may be a trigger for IgA vasculitis. with associated weight loss and in- more commonly seen as a disease for increased work of breathing be- • Hemolacria is an atypical presenta- termittent fevers, over the course of manifestation in adults. The patient lieved to be secondary to viral bron- tion of rare and common diagnoses several weeks. CT revealed multiple was treated with cefazolin, and his chiolitis. Her first hospitalization that should prompt further work- liver lesions, providing concern for lesions improved over the course of occurred at 7 weeks of age and was up. possible malignancy, although liver several weeks with resolution of his complicated by spontaneous pneu- • Acute respiratory distress can be biopsy proved otherwise, with most- hematuria by 6 months. mothorax requiring chest tube place- caused by underlying cardiac or ly liquefactive tissue and benign Is she crying blood? Joshua Price, ment. She was again hospitalized vascular anomalies and can be mis- liver parenchyma. After a large in- MD, a resident at Baystate Children’s at 5 months of age with resolution taken for common viral illnesses. fectious work-up ensued, the patient Hospital in Springfield, Mass., de- of her increased work of breathing was diagnosed with disseminated scribed a 12-year-old female who with high-flow nasal cannula. She Dr. Marsicek is a pediatric hospital Bartonella. He was treated with a 10- presented with 7 days of left-sided presented again at 7 months of age medicine fellow at Johns Hopkins All day course of azithromycin, and his hemolacria with acute vision loss with presumed bronchiolitis; howev- Children’s Hospital, St. Petersburg, Fla. symptoms resolved. and unilateral eye pain. This pa- er, she decompensated and required Dr. Wysocka is a pediatric resident at Leg blisters as an uncommon tient did not respond to outpatient intubation on the 5th day of hospi- Johns Hopkins All Children’s Hospital. Pediatric sepsis

By Ngozi Eboh, MD, and Amber Wright, Early recognition and management of sepsis venous pressure, cardiopulmonary monitor, uri- MD decreases mortality, and can be improved by initi- nary catheter, and pulse oximeter. A performance ating a recognition bundle. Multiple trigger tools bundle is important to assess adherence to the Presenters: Elise van der Jagt, MD, MPH are available, but must be combined with physi- other bundles. Session title: What you need to know about cian evaluation within 15 minutes for any patient pediatric sepsis who screens positive. Key takeaways for HM Resuscitation bundles also decrease mortality. A • Patients with severe sepsis/septic shock should Session summary: Dr. van der Jagt of the good goal is establishing IV or intraosseous access be rapidly identified with the 2014/2017 Ameri- University of Rochester (N.Y.) Medical Center, within 5 minutes, fluid administration within 30 can College of Critical Care Medicine consensus noted that the definition and management minutes, and antibiotics and inotrope administra- criteria. of sepsis in pediatrics is complex, and forms a tion in 60 minutes. Resuscitation bundles could • Efficient, time-based care should be provided spectrum of disease from sepsis to severe sepsis, include a sepsis clock, rapid response team, check during the 1st hour after recognizing pediatric and septic shock. She advised not to use the adult list, protocol, and order set. Studies show that severe sepsis/septic shock. sepsis definition in children. Sepsis is systemic mortality increases with delays in initiating fluids • Overcoming systems barriers to rapid sepsis inflammatory response syndrome in association and less fluids given. However, giving too much recognition and treatment requires sepsis with suspected or proven infection. Severe fluid also increases morbidity. It is imperative to champions in each area, continuous data collec- sepsis is sepsis with cardiovascular dysfunction, reassess after fluid boluses. Use of lactate mea- tion and feedback, persistence, and patience. respiratory dysfunction, or dysfunction of surement can be problematic in pediatrics, as nor- two other systems. Septic shock is sepsis with mal lactate can be seen with florid sepsis. Dr. Eboh is a pediatric hospitalist at Covenant cardiovascular dysfunction that persists despite Stabilization bundles are more common in the Children’s Hospital in Lubbock, Tex. Dr. Wright is a 40 mL/kg of fluid bolus in 1 hour. ICU setting. They include an arterial line, central pediatric hospitalist at Texas Tech University. June 2019 | 6 | The Hospitalist HM19 REVIEW Interprofessional rounds

By Nageshwar Jonnalagadda, sional rounds, and the role of these The University of Kentucky ship, situation monitoring, and mu- MD, MPH, FHM, and Venkatrao rounds in improving patient out- named these rounds the “Interpro- tual support. The interprofessional Medarametla, MD, SFHM, FACP come measures. fessional Teamwork Innovation team was trained and observed, and The presenters noted that the Model (ITIM),” to promote commu- a short video recording was made. Presenters: Surekha Bhamidipati, purpose of these rounds is effec- nication and patient-centered coor- This video was used as an educa- MD, FACP; Preetham Talari, MD, tive communication and efficient dinated care. Their model showed a tional tool in coaching the rest of FACP, SFHM; Mark V. Williams, MD, patient care. As shown by multiple significant reduction in readmission the team. Dr. Bhamidipati described FACP, MHM studies, there is rates, and no the importance of interprofessional Session title: Interprofessional significant impact increase in costs leaders as coaches to train other rounds: What’s the right way? in team member despite adding team members, and highlighted satisfaction, de- pharmacy and the engagement of unit leaders in Session summary: Interprofessional crease in length case managers to successfully implementing these or multidisciplinary rounds involve of stay, reduction the rounds. rounds. The Christiana Care team all members of the care delivery in adverse events, Dr. Bhamidipati used its informational technology team, including physicians, nurses, and improve- described how system to collect real-time data, case managers, social workers, ment in patient Christiana Care which were then used for team re- pharmacists, nurse facilitators, and experience. They Dr. Jonnalagadda Dr. Medarametla Health System view. of course, patients. The primary goal emphasized the designed multi- In summary, the presenters from for these rounds is patient-centered importance of implementing these disciplinary rounds based on the both the University of Kentucky care, and to improve communication rounds at the bedside, so that pa- application of Team STEPPS 2.0, a and Christiana Care highlighted among the health care team members, tients and families can be engaged teamwork system developed by the the importance of interprofessional as well as with patients and their in the patient’s care, thereby improv- Department of Defense and the rounds, as well as the need for con- families. ing closed communication among Agency for Healthcare Research and tinued measurement of process and At HM19, Dr. Talari and Dr. Wil- the team and the patient. These Quality to improve the institutional outcome metrics. liams of the University of Kentucky, rounds always offer an opportunity collaboration and communication and Dr. Bhamidipati of Christiana for the patient to ask questions of relating to patient safety. Dr. Jonnalagadda is a physician advis- Care Health System in Newark, Del., multiple health care team members The Christiana Care model is er, and Dr. Medarametla is medical di- discussed their system-based efforts as they are gathered together at the based on a few principles of team rector, Hospital Medicine, at Baystate to try to implement interprofes- same time. structure, communication, leader- Medical Center, Springfield, Mass. Things we do for no reason Practice management tips for pediatric HMGs By Weijen Chang, MD, SFHM, Dr. Orlov, of the University of Chica- FAAP go, presented another illustrative case which highlighted the need to reduce By Anika Kumar, MD, FAAP anced environment of resources, Presenters: Amit K. Pahwa, MD, vital sign frequency when appropri- technology, and institutional FAAP; Nicola Orlov, MD, MPH, FAAP ate. This was linked to her work on Presenter: H. Barrett Fromme, change [that] are in harmony, and Session title: Things we do for no reducing nighttime sleep disruptions MD, MHPE, FAAP enhances current and future po- reason (pediatrics) in hospitalized children, as part of the Session title: Practice tential to meet human aspirations SIESTA (Sleep for management tips for long-term and needs.” Session summary: As he began Inpatients: Em- success in your Pediatric Hospital by stating the Institute of Medicine powering Staff to Medicine Group Key takeaways definition of high-value care (HVC), Act) study. This led for HM Dr. Pahwa, of Johns Hopkins to a significant re- Session summary: Dr. Fromme • Advocate with Medicine, Baltimore, described HVC duction in nurse/ of the University of Chicago hospital lead- as the best care for the patient, physician inter- presented and facilitated a dialogue ership to opti- with the optimal result for the ruptions during of sustainability. The audience mize individual circumstances, at the right price. But the study period. was guided through a discussion workload and few pediatric residency programs Dr. Chang of how efficiency and resources, job demands. Dr. Kumar provide education regarding HVC, Key takeaways workload and job demands, work- • Improve care with only 11% providing a formal for HM life integration and social support, process and clinical work flow HVC curriculum. • High-value care is a key focus of and community at work can either to optimize efficiency and re- Dr. Pahwa then provided exam- systems improvement in the field lead to burnout or engagement sources. ples of cases in which HVC could of pediatric hospital medicine. within a Pediatric Hospital • Build high-functioning teams and be optimized, including reducing • Educational efforts for all levels of Medicine Group. cultivate communities of practice. rebound bilirubin levels in neo- learners is inadequate currently. For each of the four topics, Dr. • Develop goals to optimize work- natal hyperbilirubinemia, giving • QI projects to promote HVC can Fromme presented how individu- life integration. nasogastric feeds instead of IV hy- lead to reduced costs, and improve als and leaders can leverage these • Support values, autonomy, and dration in bronchiolitis, reducing quality and patient experience. areas to counteract burnout and growth to create an environment unnecessary vital sign checks, and promote engagement, leading to vi- where individuals actively value providing apple juice supplement- Dr. Chang is a pediatric hospitalist tality within the practice group. and support their colleagues. ed with liquids of choice instead at Baystate Children’s Hospital in She closed her discussion stating of more expensive oral electrolyte Springfield, Mass., and is the pediat- that sustainability is a “process Dr. Kumar is a pediatric hospitalist at solutions. ric editor of The Hospitalist. that maintains change in a bal- Cleveland Clinic Children’s Hospital. the-hospitalist.org | 7 | June 2019 COMMENTARY A “Ray of light” Finding inspiration in our patients

By Leif Hass, MD search on the amazing stability of our happiness set point: Good things and bad move our hap- rush into the room at 4:30 p.m., hoping for a piness only for a while before we return to our quick visit and maybe an early exit from the innate level of happiness. I see I had likely fallen hospital; I had been asked to see Mr. Bryant in prey to a stereotype of the disabled as heroic for room 6765 with sigmoid volvulus. just being themselves. Ray’s happiness is largely I“Hey, Dr. Hass, my brother!” he says with a huge because of his lack of self-absorption and his fo- smile. Somehow, he must have gotten a glimpse of cus on service and love. me before I could see him. I peek over the nurse’s Finishing our conversation and leaving the shoulder, and then I see that unforgettable smile room feeling enlivened, I realize that Ray‘s gener- with only a few teeth and big bright eyes. Imme- ous spirit is a gift. diately I recognize him and think, “How could I That night, my heart aches. I think about the have forgotten his name? Ray – like a beam of inadequate care that led to Ray’s profound loss of light.” He certainly had not forgotten me. function, leading to a surge of anger toward our “It’s been more than a year since I was last flawed health care system – one that routinely here,” he says proudly. lets down the most vulnerable among us. Dr. Hass is a hospitalist at Sutter Health in When we met during his last hospitalization, The next day, two sisters and an aunt join Ray Oakland, Calif. I was struck by a thought that implanted itself in his room. They ask for hugs, and I happily sup- deep in my brain: This guy is the happiest person ply them. “Ray told us about you,” says Sheila, one I have ever met. And after what must have been of his sisters. 18 hard months for him, he is still smiling – and “Well, we have been talking about him here at more than that, he is radiating love. the hospital, because he brightens everyone’s day. The fact that he is the “happiest person” is He is truly amazing. Has Ray always been so full There is only one Ray, but he made more remarkable by all the hardship he of love?” I say, hoping to get some insight into his has given me something to has endured. Ray was born with cerebral palsy remarkable spirit. and didn’t walk until he was 10. The continuous Tonya, his aunt, responds first. “We were raised aspire toward and what feels spasms in his muscles led to severe cervical disc that way – to look for the good and keep love in like urgency to do it. I want to disease. His worsening pain and weakness were our hearts. But Ray has always been the best. He missed by his health care providers until he had never, ever complains. He brings joy to so many “wake up every day and think lost significant strength in his hands and legs. people. You should see him every day out on his about what I can do to make When he finally got an MRI and then emergency scooter. That’s how he got that big sore on his people happy.” surgery, it was too late. He never regained the butt.” dexterity of his hands or the ability to walk. He Ray indeed had developed a pressure sore, one can climb onto his scooter chair only with the that was going to need some thoughtful, ongoing help of a lift. care. “Wow! How you been, Ray?” “But I finally got the right kind of cushion, be- ward fist bump from the bed and says, “I want to He replies with a phrase that jumped back out fore it was real hard,” he says. thank y’all again for everything. And I want you from my memory as he was saying it: “I just wake I move from hospitalist mode to primary care to know I love you.” up every day and think about what I can do to mode and ask about his home equipment and I find myself tearing up. “I love you too, my make people happy.” his dental care. But they all want to keep talking brother. And I am the one who should be grateful, The goosebumps rise on my arms; I remember about love. Ray.” Saying it, I feel myself playing a part in the feeling this same sense of awe the last time we “If doctors showed more love and their human cycle of gratitude. Even small gifts put us under met – a feeling of real spiritual love for this guy. side, they could bring more healing,” his sister an obligation to give back. With great gifts, the “Today I feel so much better, too. I want to says. desire to give is inescapable. thank y’all who helped my stomach go down. After 20 minutes of chatting, I pause. It is my There is only one Ray, but he has given me Man, it got so huge, I thought I might blow up.” last day on service, I had run out of medical something to aspire toward and what feels like One of the consequences of the nerve damage reason to stay and I have others to see. So, I re- urgency to do it. I want to “wake up every day he sustained is a very slow gut that has led to a luctantly give my goodbye hugs and leave. At the and think about what I can do to make people stretched-out colon. The other day, his big, floppy door, I turn back around. “Hey, Ray, can I get a happy.” colon got twisted, and neither our gastroenterolo- picture with you?” And understanding the potency of the gift gist nor radiologist was able to untwist it. He still “Yeah, I want one with you, too!” from him has alerted me to the value of looking has a tube in his rectum to help decompress his So, not surprisingly, Ray never complains. May- for other gifts and other inspirations from those bowel. be his spinal cord injury wasn’t from negligent I care for – something those of us who tend to be Ray fills me in on the details in the slightly care. Maybe he was so accustomed to looking in the “doing” part of the provider-patient rela- strained and slurred speech that sometimes past discomfort and too busy with his ministry of tionship can easily miss. comes with cerebral palsy. As he relays his story, love, it didn’t occur to him to seek care. I will never be the beacon of light and love my mind goes to work trying to diagnosis this Still, such a tragedy that he lost so much of the that Ray is, but being compelled to be my most mysterious case of happiness. How can I not try little mobility he did have. But maybe not so bad. authentic caring self with him, I see that for to get to the origins of this wellspring of love? I His injury brought him back in contact with me years I have held back – in the name of profes- can’t help but thinking: Was it Ray’s joy and his and our staff. He is still waking up trying to make sionalism – the positive emotions that naturally speech impediment that made him seem child- people happy and I can see his efforts are work- arise from the work I do. I will try to shine and like, or was it some brain injury that blessedly ing. “He made my day!” I hear from a nurse. There try to connect with that “Ray of light” residing knocked out his self-pity? I would be wallowing is a healthy buzz at the nurses’ station after visits in all my patients. I hope, too, that the cycle of in self-pity if I were as gravely disabled as he. to his room. giving that Ray started will continue spreading After a moment’s reflection, I recall the re- Before I walk out the door, he gives me an awk- to all those I care for. June 2019 | 8 | The Hospitalist PEDIATRICS N.Y. hospitals report near-universal CMV screening when newborns fail hearing tests

By M. Alexander Otto around the country have launched delayed discharge, so a switch was MDedge News similar programs, and a handful of soon made to saliva swab PCRs, REPORTING FROM PAS 2019 states – including New York – now which take seconds, with urine PCR require CMV screening for infants held in reserve to confirm positive BALTIMORE – Over the past 2 years, who fail mandated hearing tests. swabs. Northwell Health, a large medical The issue is gaining traction be- To streamline the process, a stand- system in the metropolitan New cause hearing loss is often the only ing order was added to the electron- York area, increased cytomegalovi- sign of congenital CMV, so it’s a ic records system so nurses could rus screening for infants who fail bellwether for infection. Screening order saliva PCRs without having hearing tests from 6.6% to 95% at children with hearing loss is an easy to get physician approval. “I think

five of its birth hospitals, according way to pick it up early, so steps can [that] was one of the biggest things ews n to a presentation at the Pediatric Ac- be taken to prevent problems down that’s helped us,” Dr. Chauhan said. edge ademic Societies annual meeting. the road. As it is, congenital CMV Children who test positive must /M d

Three cases of congenital cy- is the leading nongenetic cause of have urine confirmation within 21 tt O tomegalovirus (CMV) have been hearing loss in infants, accounting days of birth; most are long gone nder O picked up so far. The plan is to roll for at least 10% of cases. from the hospital by then and have

the program out to all 10 of the The Northwell program kicked to be called back in. “We haven’t lost M. A lex system’s birth hospitals, where over off with an education campaign to anyone to follow-up, but it can be Dr. Alia Chauhan 40,000 children are born each year. build consensus among pediatri- stressful trying to get someone to “We feel very satisfied and proud” cians, hospitalists, and nurses. A fly- come back,” she said. These days, Dr. Chauhan said, if of the progress that’s been made at er was made about CMV screening Six of 449 infants have screened children have a positive saliva PCR Northwell in such a short time, said for moms whose infants fail hearing positive on saliva – three were but later turn out to have normal Alia Chauhan, MD, a Northwell pedi- tests, printed in both English and false positives with negative urine hearing, and are otherwise free of atrician who presented the findings. Spanish. screens. Of the three confirmed symptoms with no CMV risk factors, Northwell launched its “Hearing Initially, the program used urine cases, two infants later turned out “we are not confirming with urine.” Plus” program in 2017 to catch the in- PCR [polymerase chain reaction] to have normal hearing on repeat Dr. Chauhan did not have any fection before infants leave the hos- to screen for CMV, but waiting for testing and were otherwise asymp- disclosures. No funding source was pital. Several other health systems infants to produce a sample often tomatic. mentioned. Comorbid depression POLICY & worsens many pediatric ADVOCACY hospital outcomes

By Christopher Palmer This analysis is based on 17,073 MDedge News pairs of patients with and with- FROM THE JOURNAL OF AFFECTIVE out depression that were created DISORDERS through one-to-one propensity score matching. The investigators omorbid depression signifi- drew these pairs from an estimated cantly increased hospitaliza- 937,971 patients in the Kids’ Inpa- Participate in Ction costs, length of stay, and tient Database for 2012 who were mortality among pediatric patients, identified as being aged 6 years and according to a study in the Journal older and having any of the 10 of the policymaking. of Affective Disorders. most common diagnoses other than The investigators led by Mayowa affective disorders. The investiga- Olusunmade, MD, MPH, of New Jer- tors then determined which children sey Medical School, Newark, found among those identified had comor- that, compared with those among bid depression (2.9%) and which did On and off Capitol Hill, nondepressed pediatric patients, not (97.1%) to create the propensity hospitalization costs were $2,961 score–matched pairs. make your voice heard. higher (P less than .001), length of One limitation in this study is that stay was 0.89 days longer (P less the mean age was 17.5 years because Advocate for your patients and your specialty. than .001), and odds of death as an depression diagnosis is more atyp- outcome while hospitalized was ical among younger patients such 1.77 times higher (P = .013) among that adolescents were dispropor- Visit SHM’s Legislative Action Center. depressed pediatric patients. On the tionately represented. hospitalmedicine.org/takeaction other hand, depressed patients had The study did not receive funding, 0.3 fewer procedures (P less than and the authors declared there are .001) than nondepressed patients. no conflicts of interest. the-hospitalist.org | 9 | June 2019 VA hospitalist Continued from page 1

(seeing patients 5 months a year way we make sure we’re collabo- While the VA is a “great health at the Washington VAMC involves on a consultative or inpatient basis rating as a team. I don’t know that system,” Dr. Tuck said, the challenge a broadly representative team from with resident teams); administrative medical school prepares you for this is learning how to work with its bu- nursing, case management, social in a variety of roles; and research. kind of teamwork. Unless you bring reaucracy. “If you don’t know how work, the business office, medical He has academic appointments at a background in business, you can the system works, it can seem to get coding, utilization management, and the George Washington University really struggle.” in your way.” But overall, he said, administration that convenes every (GWU) School of Medicine and at the VA functions well and compares morning to discuss patient naviga- the Uniformed Services University Interest in hospital medicine favorably with private sector hospi- tion and difficult discharges. “Every- of Health Sciences in Bethesda, Md. “Throughout our medical training tals and health systems. That was one sits around a big table, and the He developed the coursework for we do a variety of rotations and also the conclusion of a recent study six hospital medicine teams rotate teaching evidence-based medicine to clerkships. I found myself falling in in the Journal of General Internal through every 15 minutes to review first- and second-year medical stu- love with all of them – surgery, psy- Medicine, which compared the qual- their patients’ admitting diagnoses, dents at GWU. chiatry, obstetrics, and gynecology,” ity of outpatient and inpatient care barriers to discharge and plans of He is also part of a large research Dr. Tuck explained, as he reflected in VA and non-VA settings using care.” consortium with five sites and $7.5 At the patient’s bedside, a Focused million in funding over 5 years from I say: ‘This is how I want Interdisciplinary Team (FIT) model, NIH’s National Institute on Minori- “ which Dr. Tuck helped to implement, ty Health and Health Disparities to rounds to be run. What are your incorporates a four-step process study how genetic information from expectations?’ That way we with clearly defined roles for the at- African American patients can predict make sure we’re collaborating as tending, nurse, pharmacist, and case their response to cardiovascular med- manager or social worker. “Since im- ications. He serves as the study’s site a team. I don’t know that medical plementation, our data show overall Principal Investigator at the VAMC. school prepares you for this kind reductions in lengths of stay,” he said. Opportunities to advance his Dr. Tuck urges other hospitalists leadership skills have included the of teamwork. Unless you bring a to pursue opportunities available VA’s Aspiring Leaders Program and background in business, you can to them to develop their leadership Leadership Development Mentoring skills. “Look to your professional so- Program, which teach leadership Dr. Matthew Tuck really struggle. cieties such as the Society of General skills on topical subjects such as ” Internal Medicine (SGIM) or SHM.” teaching, communications skills, and on how he ended up in hospital recent performance measure data.1 For example, SGIM’s Academic Hospi- finance. The Master Teacher Lead- medicine. “As someone who was The authors concluded that the VA talist Commission, which he cochairs, ership Development Program for interested in all of these different system performed similarly or bet- provides a voice on the national medical faculty at GWU, where he fields of medicine, I considered my- ter than non-VA health care on most stage for academic hospitalists and attended medical school and did his self a true medical generalist. And in nationally recognized measures of cosponsors with SHM an annual Ac- internship and residency, offers six hospitalized patients, who struggle inpatient and outpatient care qual- ademic Hospitalist Academy to sup- intensive, classroom-based 8-week with all of the different issues that ity, although there is wide variation port career development for junior courses over a 1-year period. They bring them to the hospital, I saw a between VA facilities. academic hospitalists as educational cover various topical subjects with compilation of all my experiences in leaders. Since 2016, its Distinguished faculty from the business world residency training combined in one Work with the team Professor of Hospital Medicine rec- teaching principles of leadership. setting.” Another major interest for Dr. Tuck ognizes a professor of hospital med- The program includes a mentoring Hospital medicine was a relatively is team-based learning, which also icine to give a plenary address at the action plan for participants and young field at that time, with few grew out of his GWU leadership SGIM national meeting. leads to a graduate certificate in academic hospitalists, he said. “But certificate course work on teach- SGIM’s SCHOLAR Project, a sub- leadership development from GWU’s I had good mentors who encour- ing teams and team development. group of its Academic Hospitalist Graduate School of Education and aged me to pursue my educational, He is working on a draft paper for Commission, has worked to identify Human Development at the end of research, and administrative in- publication with coauthor Patrick features of successful academic hos- the year’s studies. terests. My affinity for the VA was Rendon, MD, associate program pitalist programs, with the results Dr. Tuck credits completing this also largely due to my training. We director for the University of New published in the Journal of Hospital kind of coursework for his current worked in multiple settings – aca- Mexico’s internal medicine residency Medicine.3 position of leadership in the VA demic, community-based, National program, building on the group de- “We learned that what sets suc- and he tries to share what he has Institutes of Health, and at the VA.” velopment stage theory – “Forming/ cessful programs apart is their lead- learned with the medical students Dr. Tuck said that, of all the set- Storming/Norming/Performing” – ership – as well as protected time for he teaches. tings in which he practiced, he felt developed by Tuckman and Jenson.2 scholarly pursuits,” he said. “We’re “When I was starting out as a phy- the VA truly trained him best to be The theory offers 12 tips for opti- all leaders in this field, whether we sician, I never received training in a doctor. “The experience made me mizing inpatient ward team perfor- view ourselves that way or not.” how to lead a team. I found myself feel like a holistic practitioner,” he mance, such as getting the learners trying to get everything done for my said. “The system allowed me to take to buy in at an early stage of a proj- References patients while teaching my learners, the best care of my patients, since I ect. “Everyone I talk to about our re- 1. Price RA et al. Comparing quality of care and I really struggled for the first didn’t have to worry about whether search is eager to learn how to apply in Veterans Affairs and non–Veterans Affairs couple of years to manage these com- I could make needed referrals to these principles. I don’t think we’re settings. J Gen Intern Med. 2018 Oct;33(10):1631- 8. peting demands on my time,” he said. specialists. Very early in my intern- unique at this center. We’re con- 2. Tuckman B, Jensen M. Stages of small group Now, on the first day of a new ship year we were seeing very sick stantly rotating learners through development revisited. Group and Organiza- clinical rotation, he meets one-on- patients with multiple comorbidi- the program. If you apply these tional Studies. 1977;2:419-27. one with his residents to set out ties, but it was easy to get a social principles, you can get learners to 3. Seymann GB et al. Features of success- goals and expectations. “I say: ‘This worker or case manager involved, be more efficient starting from the ful academic hospitalist programs: Insights from the SCHOLAR (Successful hospitalists in is how I want rounds to be run. compared to other settings, which first day,” he said. academics and research) project. J Hosp Med. What are your expectations?’ That can be more difficult to navigate.” The current inpatient team model 2016 Oct;11(10):708-13. June 2019 | 10 | The Hospitalist COMMENTARY Discharge before noon: An appropriate metric for efficiency?

By Jennifer K. Chen, MD for pediatric hospitalization) include How does your institution try to demonstrating the ability to drink make discharge processes more ef- first heard the term “discharge enough liquids to stay hydrated. ficient? Is it actually possible to do before noon” (DCBN) as a third- Who’s going to force children to everything more quickly without year medical student starting my stay up all night sipping fluids (plus sacrificing quality or trainee edu- internal medicine rotation. The changing all those diapers or taking cation? Whether your patients are Ibasic idea made sense: Get patients them to the bathroom)? If the child kids, adults, or both, there are likely out of the hospital early so rooms stays on intravenous fluids over- many issues in common where we can be cleaned more quickly and night, we have to monitor at least could all learn from each other. new patients wouldn’t have to wait through breakfast, likely lunch, thus We discussed this topic in #JHM- so long in the ED. making DCBN nearly impossible. Chat on Twitter. New to Twitter or It quickly became apparent, how- In a January 2019 article in the not familiar with #JHMChat? Since Dr. Chen is a pediatric hospital ever, that a lot of moving parts had Journal of Hospital Medicine, Hailey October 2015, #JHMChat has hosted medicine fellow at Rady Children’s to align perfectly for DCBN. Even I. James, MHA (@Haileyjms on Twit- discussions of articles spanning a Hospital, University of California, San if we prioritized rounding on dis- ter), and her colleagues demonstrat- wide variety of topics related to car- Diego. She serves as a fellow dis- chargeable patients (starting 8-9 ed an association between DCBN ing for hospitalized patients. All are trict representative for the American a.m. depending on the service/day), and decreased length of stay (LOS) welcome to join, including students, Academy of Pediatrics, and is an ac- they still needed prescriptions filled, for medical but not surgical pedi- residents, nurses, practicing hospi- tive #tweetiatrician at @DrJenChen- normal clothes to wear, and a way to atric discharges.1 This made them talists, and more. It’s a great oppor- 4kids. get home, which wasn’t easy to coor- question if DCBN is an appropriate tunity to virtually meet and learn dinate while we were still trying to metric for discharge efficiency, from others while earning free CME. References see all the other patients. as well as workflow differences To participate in future chats, type 1. James HJ et al. The association of discharge Fast forward through 5 years of between services. Many hospitals, #JHMChat in the search box on before noon and length of stay in hospitalized residency/fellowship experience and however, still try to push DCBN as the top right corner of your Twitter pediatric patients. J Hosp Med. 2019;14(1):28- 32. doi: 10.12788/jhm.3111. DCBN seems even more unrealistic a goal (see Destino et al in the same homepage, click on the “Latest” tab in hospitalized pediatric patients. As January 2019 issue of JHM2), which at the top left to see the most recent 2. Destino L et al. Improving patient flow: anal- ysis of an initiative to improve early discharge. a simple example, discharge criteria could potentially lead to people try- tweets, and join the conversation J Hosp Med. 2019;14(1):22-7. doi: 10.12788/ for dehydration (a common reason ing to game the system. (don’t forget the hashtag)! jhm.3133.

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the-hospitalist.org | 11 | June 2019 POLICY CBO predicts more Medicare spending with drug rebate proposal

By Gregory Twachtman plans currently use the rebates they receive from lization stemming from implementing the pro- MDedge News drug companies to lower premiums across the posed rule would increase federal spending for board. beneficiaries who are not enrolled in the low-in- edicare spending on pharmaceuticals However, some beneficiaries “would pay lower come subsidy program over the 2020-2029 period is projected to increase if the Centers prices on their prescription drugs, and for some by a total of about 2% or $10 billion,” the report for Medicare & Medicaid Services fi- beneficiaries, those reductions would be greater noted. nalizes changes to drug rebates in the than their premium increases,” the CBO stated in But the increase in utilization would have a MMedicare program. its report. For beneficiaries who use few drugs or net positive effect on Medicare spending for this The Congressional Budget Office is estimating who use drugs that have no significant rebates, population, as more beneficiaries followed their that Medicare spending would increase by $170 “the premium increase would outweigh the price drug regimens resulting in lower spending for billion from 2020 to 2029 if the rebate rule goes reduction.” physician and hospital services under Medicare into effect, according to a report released May 2. Another reason federal spending would in- Part A and Part B by an estimated $20 billion over The proposed rule, issued Jan. 31, would make crease under this proposal is an expected in- the same period, according to the CBO. it illegal for drug manufacturers to pay rebates to crease in utilization that would come with the “On net, those effects are projected to reduce health plans and pharmacy benefit managers in lowering of prices. Medicare spending by $10 billion over the 2020- return for better formulary placement. Instead “In CBO’s estimate, the additional Part D uti- 2029 period,” according to the report. of rebates, manufacturers could offer discounts directly to beneficiaries by lowering list prices or making a payment to the pharmacy for the full amount of the negotiated discount – a charge- back. Under the proposal, a beneficiary’s cost sharing would be based on the lower list price or the price after the chargeback. The CBO’s projected spending increases are based on the assumption that manufacturers will withhold 15% of current-law rebates, as well as increases in federal subsidies for premiums, changes in annual thresholds to beneficiary cost stoc K hin K sharing, and the cost of implementing the charge- back system. enishirotie / t The agency expects premiums to rise, as many K CDC warns against misuse of opioid-prescribing guideline

By Alicia Gallegos line to patients in active cancer cians to start opioids at the lowest that insurers are inappropriately MDedge News treatment, patients experiencing effective dosage and avoid increas- applying the recommendations to acute sickle cell crises, or patients ing dosage to 90 morphine–milli- active cancer patients when making fficials at the Centers for experiencing postsurgical pain, Dr. gram equivalents per day or more, coverage determinations. Disease Control and Pre- Dowell wrote. The American Society of Clinical O vention are warning against The guideline Misapplication examples Oncology, the National Comprehen- the misapplication of the agency’s offers guidance sive Cancer Network, and the Amer- 2016 guidelines on opioid prescrib- to clinicians include patients ican Society of Hematology raised ing, as well as clarifying dosage rec- treating chronic experiencing acute sickle the issue in a letter to the CDC in ommendations for patients starting pain in adults February. In response, Dr. Dowell or stopping pain medications. who are already cell crises or patients clarified that the recommendations In a perspective published in the receiving opioids long-term at high experiencing postsurgical are not intended to deny clinically New England Journal of Medicine, dosages, she noted. It includes ad- pain. appropriate opioid therapy to any lead author Deborah Dowell, MD, vice on maximizing nonopioid treat- patients who suffer chronic pain, chief medical officer for the CDC’s ment, reviewing risks associated but rather to ensure that physicians National Center for Injury Preven- with continuing high-dose opioids, that statement does not suggest and patients consider all safe and tion and Control, conveyed concern and collaborating with patients who discontinuation of opioids already effective treatment options. that some policies and practices de- agree to taper dosage, among other prescribed at high dosages, accord- In the perspective, Dr. Dowell rived from the 2016 CDC Guideline guidance. ing to the CDC’s clarification. wrote that the CDC is evaluating the for Prescribing Opioids for Chronic Any application of the guideline’s The guidance also does not apply intended and unintended impact of Pain are inconsistent with the rec- dosage recommendation that results to patients receiving or starting the 2016 opioid-prescribing guideline ommendations and often go beyond in hard limits or “cutting off” opioids medication-assisted treatment for on clinicians and patient outcomes, their scope. is also an incorrect use of the recom- opioid use disorder. and that the agency is committed Misapplication examples include mendations, according to Dr. Dowell. The commentary comes after a to updating the recommendations inappropriately applying the guide- While the guideline advises clini- trio of organizations raised concerns when new evidence is available. June 2019 | 12 | The Hospitalist ®

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HOSP_13.indd 1 5/15/2019 3:19:45 PM INNOVATIONS | By Suzanne Bopp Bringing QI training to an IM residency program Consider a formal step-wise curriculum

or current and future hospitalists, there’s no doubt that knowledge of quality improvement (QI) fundamentals is an important component of a successful Fpractice. One physician team set out to provide their trainees with that QI foundation and de- scribed the results. “We believed that implementing a formal step-wise QI curriculum would not only meet the Accreditation Council of Graduate Medical Education (ACGME) requirements, but also in- crease residents’ knowledge of QI fundamentals and ultimately establish a culture of continuous improvement aiming to provide high-value care to our health care consumers,” said lead author J. Colt Cowdell, MD, MBA, of Mayo Clinic in Jack- /t hinkstoCk avebreakmedia

sonville, Fla. W Prior to any interventions, the team surveyed in- ternal medicine residents regarding three unique “Keys to successful implementation includ- to mentor residents and help lead multidisci- patient scenarios and scored their answers. Res- ed a thorough explanation of the need for this plinary team-based projects,” Dr. Cowdell said. idents were then assigned to one of five unique curriculum to the learners and ensuring that QI projects for the academic year in combination QI teams were multidisciplinary – residents, QI Reference with a structured didactic QI curriculum. experts, nurses, techs, pharmacy, administrators, Cowdell JC et al. Integration of a novel quality improvement After the structured progressive curriculum, etc.,” said Dr. Cowdell. curriculum into an internal medicine residency program. in combination with team-based QI projects, res- For hospitalists in an academic setting, this work Abstract published at Hospital Medicine 2018; Apr 8-11; idents were surveyed again. Results showed not can provide a framework to incorporate QI into Orlando. Abstract 54. https://www.shmabstracts.com/abstract/ integration-of-a-novel-quality-improvement-curriculum-in- only increased QI knowledge, but also improved their residency programs. “I hope, if they have a to-an-internal-medicine-residency-program/. Accessed Dec patient safety and reduced waste. passion for QI, they would seek out opportunities 11, 2018. New help for Quick Byte: peanut allergies Cost conversations Breakthrough therapy holds potential Patients want to talk

hen it comes to anaphylaxis alent of two peanuts without allergic eventy percent of Amer- to help health care providers. episodes leading to pediatric symptoms. Just 4% of the 124 children icans would like to have Practice briefs for these kinds W intensive care–unit stays, given a placebo powder were able to S conversations about the of conversations are now avail- peanuts are the most common culprit. consume that amount of peanut with- costs of care with their health able on America’s Essential Now the results of a recent clinical tri- out reacting. The treatment was not ef- care providers, but only 28% Hospitals’ website (https://es- al may lead to approval of the first oral fective for the small number of adults do so, according to polling con- sentialhospitals.org/cost-care/ in the study. ducted for the Robert Wood practice-briefs/). This trial of the drug, called AR101 Johnson Foundation (RWJF) by and developed by Aimmune Therapeu- Avalere Health. Reference tics, was published in November 2018 in With those polling results Ganos E et al. Talking about costs: Inno- the New England Journal of Medicine. in hand, 2 years ago RWJF and vation in clinician-patient conversations. Health Affairs. Published Nov 27, 2018. doi: The company has submitted a biolog- Avalere Health launched the 10.1377/hblog20181126.366161. Accessed ics license application to the U.S. Food Cost Conversation projects Dec 11, 2018. and Drug Administration, and because the drug has been designated a break- through therapy, it will go through an

/F otolia mates accelerated approval process. It could be on the market by the end of 2019. medication to ameliorate reactions in children with severe peanut allergies. Reference After 6 months of treatment and 6 Rabin RC. New peanut allergy drug shows ‘life- months of maintenance therapy, two- saving’ potential. New York Times. Nov 18, 2018. https://www.nytimes.com/2018/11/18/well/live/ thirds of the 372 children who received new-peanut-allergy-drug-shows-lifesaving-poten-

this treatment could ingest the equiv- tial.html. Accessed Nov 26, 2018. 778/t hinkstoCk Utah June 2019 | 14 | The Hospitalist INNOVATIONS | By Suzanne Bopp Reducing adverse drug reactions Inpatient/outpatient transition eased

dverse drug reactions such as warfarin or glucose-lower- generated an estimated savings of “Decisions about drug therapy in are a problem hospital- ing drugs, and a history of previ- $6.6 million per year in avoided hos- the hospital may seem reasonable in ists encounter often. An ous acute care use resulting from pitalizations. the short term but often won’t stick estimated 9% of hospital medication-related problems. The There are two major takeaways, in the long term unless there is a co- Aadmissions in older adults are the hospital pharmacist would then said Dr. Steinman, who is based in ordinated care that can help ensure result of adverse drug reactions, and meet with the patient to reconcile the division of geriatrics at the Uni- appropriate follow-through once up to one in five adults experience medications and facilitate a coor- versity of California, San Francisco: patients return home,” Dr. Steinman an adverse drug reaction during dinated hand-off to a community It’s critical to focus on transitions said. “The study that the editorial hospitalization. pharmacist, who would meet with and coordination between inpatient references is a systems intervention “Many interventions have been the patient after discharge. and outpatient care to address med- that hospitalists can advocate for in tried to solve this problem, and In addition to a 36% reduction ication-related problems, and phar- their own institutions, but in the im- certain of them have worked, but in the rate of medication-related macists can be extremely helpful in mediate day-to-day, trying to ensure to date we don’t have any great solu- hospitalizations, the intervention that. solid coordination of medication tions that meaningfully impact the management from the inpatient to rate of these events in a way that’s outpatient setting is likely to be very feasible in most health care environ- helpful for their patients.” ments, so any efforts to reduce the The long-term outcomes of hos- burden of these problems in older pitalized patients are largely influ- adults could be hugely beneficial,” enced by getting them set up with said Michael Steinman, MD, author appropriate community resources of an editorial highlighting a new and supports once they leave the approach. hospital, he added, and the hospital His editorial in BMJ Quality & can play a critical role in putting Safety cites research on the Pharm- these pieces into place. 2Pharm program, implemented in k six Hawaiian hospitals, in which Reference

hospital-based pharmacists identi- hinksto C Steinman MA. Reducing hospital admissions fied inpatients at high risk of med- for adverse drug events through coordinated pharmacist care: Learning from Hawai’i without ication misadventures with criteria a field trip. BMJ Qual Saf. Epub 2018 Nov 24. such as use of multiple medications, moodboard / t doi: 10.1136/bmjqs-2018-008815. Accessed Dec

redit 11, 2018. presence of high-risk medications C Creating better performance incentives P4P programs suffer from several flaws

any performance improvement programs on physician professionalism through nonfinan- try to create a higher value health system cial rewards, resources for quality improvement, Mby incentivizing physicians and health team-based assessments, and emphasizing con- systems to behave in particular ways. These have tinuous learning and organizational culture,” often been pay-for-performance programs that he noted. Performance programs would take a offer bonuses or impose penalties depending on more global view of clinical care by emphasizing how providers perform on various metrics. culture, teams, trust, and learning. Such a system “In theory, this makes sense,” said Dhruv would allow hospitalists and other physicians to Khullar, MD, MPP, lead author of a JAMA article worry less about meeting specific metrics and fo- about the future of incentives, and assistant cus more on providing high-quality care to their professor at Weill Cornell Medicine in New patients. York. “But in practice, these programs have “I would hope physicians, payers, and admin- not been successful in consistently improving istrators would reconsider some previously held quality, and sometimes they have been coun- beliefs about quality improvement, especially the terproductive. In our article, we argued that idea that better quality requires giving people focusing too narrowly on financial rewards is bonus payments or imposing financial penalties,” not the right strategy to improve health system Dr. Khullar said. “We believe the next wave of per- performance – and is sometimes at odds with formance improvement programs should enter- the physician professionalism and what really tain other paths to better quality, which are more motivates most clinicians.” in line with human motivation and physician Pay-for-performance programs suffer from sev- professionalism.” eral fundamental flaws: They focus too narrowly es ma G on financial incentives and use centralized ac- Reference i countability instead of local culture, for example, Khullar D et al. Professionalism, performance, and the future of Dr. Khullar said. physician incentives. JAMA. 2018 Nov 26 (Epub ahead of print). /G etty reatarka

“A better future state would involve capitalizing doi: 10.1001/jama.2018.17719. Accessed Dec 11, 2018. C the-hospitalist.org | 15 | June 2019 NEWS Long-term antibiotic use tied to heightened stroke, CHD risk Alteration of gut microorganisms at issue

By Jake Remaly to cardiovascular disease risk. MDedge News “Antibiotic use is the most critical FROM THE EUROPEAN HEART factor in altering the balance of mi- JOURNAL croorganisms in the gut,” said lead investigator Lu Qi, MD, PhD, in a mong middle-aged and news release. “Previous studies have ulan E

older women, 2 or more shown a link between alterations in t , i

months’ exposure to the microbiotic environment of the Q u antibiotics is associated gut and inflammation and narrow- l

Awith an increased risk of coronary ing of the blood vessels, stroke, and ssor

heart disease or stroke, according heart disease,” said Dr. Qi, who is the rof E to a study in the European Heart director of the Tulane University p Journal. Obesity Research Center in New and Women in the Nurses’ Health Orleans and an adjunct professor ournal

Study who used antibiotics for 2 or of nutrition at Harvard T.C. Chan J art more months between ages 40 and School of Public Health in Boston. E 59 years or at age 60 years and older To evaluate associations between an H had a significantly increased risk of life stage, antibiotic exposure, and urop E cardiovascular disease, compared subsequent cardiovascular disease, E with those who did not use antibiot- researchers analyzed data from 36,429 ics. Antibiotic use between 20 and 39 participants in the Nurses’ Health middle, and late adulthood. The ques- thors noted. Whether these findings years old was not significantly relat- Study. The women were at least 60 tionnaire asked participants to indi- apply to men and other populations ed to cardiovascular disease. years old and had no history of car- cate the total time using antibiotics requires further study, they said. Prior research has found that diovascular disease or cancer when with eight categories ranging from Because of the study’s observa- antibiotics may have long-lasting they completed a 2004 questionnaire none to 5 or more years. tional design, the results “cannot effects on gut microbiota and relate about antibiotic usage during young, The researchers defined incident show that antibiotics cause heart cardiovascular disease as a composite disease and stroke, only that there endpoint of coronary heart disease is a link between them,” Dr. Qi said. (nonfatal myocardial infarction or fa- “It’s possible that women who re- tal coronary heart disease) and stroke ported more antibiotic use might be (nonfatal or fatal). They calculated sicker in other ways that we were person-years of follow-up from the questionnaire return date until date of cardiovascular disease diagnosis, Our study suggests death, or end of follow-up in 2012. Women with longer duration of that“ antibiotics should be antibiotic use were more likely to used only when they are use other medications and have unfavorable cardiovascular risk absolutely needed. … The profiles, including family history of shorter time of antibiotic myocardial infarction and higher use the better. body mass index. Antibiotics most often were used to treat respiratory ” infections. During an average fol- unable to measure, or there may be low-up of 7.6 years, 1,056 participants other factors that could affect the SHM’s QI Enthusiast Webinar Series developed cardiovascular disease. results that we have not been able Learn about QI best practices and success In a multivariable model that take account of.” stories from fellow SHM members. CME and adjusted for demographics, diet, “Our study suggests that antibiot- MOC credits are provided. lifestyle, reason for antibiotic use, ics should be used only when they medications, overweight status, and are absolutely needed,” he conclud- Attendees are allotted ample time for a live other factors, long-term antibiotic ed. “Considering the potentially cu- Q&A session with guest panelists. use – 2 months or more – in late mulative adverse effects, the shorter adulthood was associated with sig- time of antibiotic use the better.” nificantly increased risk of cardio- The study was supported by Na- Browse our webinars at hospitalmedicine.org/QI vascular disease (hazard ratio, 1.32), tional Institutes of Health grants, as was long-term antibiotic use in the Boston Obesity Nutrition middle adulthood (HR, 1.28). Research Center, and the United Although antibiotic use was States–Israel Binational Science self-reported, which could lead to Foundation. One author received misclassification, the participants support from the Japan Society for were health professionals, which the Promotion of Science. The au- may mitigate this limitation, the au- thors had no conflicts of interest. June 2019 | 16 | The Hospitalist NEWS Biomarker-based score predicts poor outcomes after acute ischemic stroke Diagnostic accuracy was 82 percent

By Andrew D. Bowser cohort studies of pa- The use of a biomarker MDedge News tients with ischemic increases“ prognostic REPORTING FROM AAN 2019 stroke, he said. accuracy, allowing us to The four-item PHILADELPHIA – A prognostic score for acute prognostic score personalize prognosis in ischemic stroke that incorporates copeptin lev- devised by Dr. De the frame of individualized, els, age, recanalization, and National Institutes Marchis and his

of Health Stroke Scale score has been externally coinvestigators, k precision medicine. … validated and accurately predicts unfavorable which they call the The observed outcomes hinksto C outcome, according to research presented at the CoRisk score, was matched well with the

annual meeting of the American Academy of developed based on kdevil / t

Neurology. a derivation cohort sto C expected outcomes. Although the four-item score could not be val- of 319 acute isch- ” idated for mortality prediction, it had reasonable emic stroke patients and a validation cohort of the patients were reclassified based on addi- accuracy for predicting unfavorable functional including another 783 patients in the Copeptin tion of the biomarker data. outcome, defined as disability or mortality 3 for Risk Stratification in Acute Stroke Patients By contrast, the score is not well suited to pre- months after ischemic stroke, Gian Marco De (CoRisk) Study. dict mortality alone at 3 months, the results of Marchis, MD, of the department of neurology Diagnostic accuracy was 82% for the endpoint the analyses showed. and the stroke center at University Hospital Ba- of unfavorable functional outcome at 3 months, The algorithm used to calculate the score based sel (Switzerland), said in a presentation. according to Dr. De Marchis. on its four variables is somewhat complex, but “The use of a biomarker increases prognostic “The observed outcomes matched well with the available as a free app and online calculator, Dr. accuracy, allowing us to personalize prognosis in expected outcomes,” he said in his presentation. De Marchis said. the frame of individualized, precision medicine,” Further analyses demonstrated that the ad- Dr. De Marchis and his coauthors had nothing Dr. De Marchis said. dition of copeptin indeed contributed to the to disclose related to their study. A full report on Copeptin has been linked to disability and diagnostic accuracy of the score, improving the the study was published ahead of print on March mortality at 3 months in two independent, large classification for 46%; in other words, about half 1 in Neurology.

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the-hospitalist.org | 17 | June 2019 Key Clinical Question Adjuvant corticosteroids in hospitalized patients with CAP When is it appropriate to treat?

By Andrew S. Parsons, MD, MPH; Bahnsen Miller, MD; and George Hoke, MD

Case A 55-year-old male with a history of tobacco use disorder presents with 2 days of productive cough, fever, chills, and mild shortness of breath. T 38.4, HR 89, RR 32, BP 100/65, 02 sat 86% on room air. Exam reveals di- minished breath sounds and positive egophony over the right lung base. Dr. Parsons is an assistant professor at the University of Virginia and a hospi- WBC is 16,000 and BUN 22. Chest talist at the University of Virginia Medical Center in Charlottesville. Dr. Miller is x-ray reveals right lower lobe consol- an assistant professor at the University of Virginia and a hospitalist at the Uni- idation. He is given ceftriaxone and versity of Virginia Medical Center. Dr. Hoke is Associate Director of Hospital azithromycin. Medicine and Faculty Development at the University of Virginia . /T HINKSTOCK STOCKDEVIL

Brief overview of the issue systemic corticosteroids may reduce the inflam- patients with CAP of varying severities. Community-acquired pneumonia (CAP) is the matory response from the infection by down-reg- The Cochrane meta-analysis, the largest and most leading cause of infectious disease–related death ulating this proinflammatory cytokine production. recent dataset, included 13 trials with a combined in the United States. Mortality associated with Almost all of the major decisions regarding 1,954 adult patients and found that corticosteroids CAP is estimated at 57,000 deaths annually and management of CAP, including diagnostic and significantly lowered mortality in hospitalized pa- occurs largely in patients requiring hospitaliza- treatment issues, revolve around the initial as- tients with severe CAP with a number needed to tion.1 The 30-day mortality rate in patients who are sessment of severity of illness. Between 40% and treat of 19.7 In this group with severe CAP, mortality hospitalized for CAP is approximately 10%-12%.2 60% of patients who present to the emergency was lowered from 13% to 8% and there were sig- After discharge from the hospital, about 18% of pa- department with CAP are admitted4 and approx- nificantly fewer episodes of respiratory failure and tients are readmitted within 30 days.3 An excessive imately 10% of hospitalized patients with CAP shock with the addition of corticosteroids. No ef- inflammatory cytokine response may be a major require ICU admission.5 Validated instruments fect was seen on mortality in patients with less se- contributor to the high mortality rate in CAP and such as CURB-65, the pneumonia severity index vere CAP. In those patients who received adjuvant (PSI), and guidelines from the Infectious Diseases corticosteroids, length of hospital stay decreased by Society of America (IDSA)/American Thoracic 3 days, regardless of CAP severity.7 Society (ATS) may predict severity of illness but The IDSA meta-analysis was similar and in- should always be supplemented with physician cluded 1,506 patients from six trials.8 In contrast determination of subjective factors when deter- with the Cochrane study, this analysis found cor- mining treatment.5 Although there is no con- ticosteroids did not significantly lower mortality census definition of severe pneumonia, studies in patients with severe CAP but did reduce time generally define the condition in the following or- to clinical stability and length of hospital stay der of preference: PSI score of IV or V followed by by over 1 day. This study also found significantly CURB-65 score of two or greater. If these scoring more CAP-related, 30-day rehospitalizations (5% modalities were not available, the IDSA/ATS cri- vs. 3%; defined as recurrent pneumonia, other teria was used (1 major or 3 minor). Others define infection, pleuritic pain, adverse cardiovascular severe CAP as pneumonia requiring supportive therapy within a critical care environment. Key Points

Overview of the data • For patients hospitalized with severe The use of corticosteroids in addition to antibiot- CAP, recent evidence supports the use of ics in the treatment of CAP was proposed as early low-dose, short-course, systemic corticoster- as the 1950s and yet only in the last decade has oids in addition to standard therapy. the body of evidence grown significantly.5 There • Among hospitalized patients with nonsevere is evidence that corticosteroids suppress inflam- CAP, the benefit is not well defined. Stud- mation without acutely impairing the immune ies suggest these patients may benefit from response as evidenced by a rapid and sustained reduced time to clinical stability and reduced decrease in circulating inflammatory markers length of hospital stay. However, they may such as C-reactive protein and interleukin 6 and be at risk for significantly more CAP-related, no effect on the anti-inflammatory interleukin 30-day rehospitalizations and hyperglycemia. 10.6 Within the last year, three meta-analyses, one • Further prospective, randomized controlled by the Cochrane Library, one by the IDSA, and a studies are needed to further delineate the third in the American Journal of Emergency Med- patient population who will most benefit icine, addressed the role of routine low-dose (20- from adjunctive corticosteroids use, includ- 60 mg of prednisone or equivalent), short-course ing dose and duration of treatment. (3-7 days) systemic corticosteroids in hospitalized June 2019 | 18 | The Hospitalist Additional Readings Figure CLINICAL | Key Clinical Question

• Blum CA et al. Adjunct prednisone thera- Bottom line py for patients with community-acquired For patients hospitalized pneumonia: A multicentre, double-blind, with severe communi- randomised, placebo-controlled trial. Lancet. ty-acquired pneumonia, 2015 Jan 18; [e-pub ahead of print] (http:// recent evidence supports dx.doi.org/10.1016/S0140-6736(14)62447-8). the use of low-dose, • Briel M et al. Corticosteroids in patients hospi- short-course, systemic talized with community-acquired pneumonia: corticosteroids in addi- Systematic review and individual patient data tion to standard therapy. meta-analysis. Clin Infect Dis. 2018 Feb 1; 66:346 (https://doi.org/10.1093/cid/cix801). References • Feldman C et al. Corticosteroids in the 1. Ramirez J et al. Adults hospi- adjunctive therapy of community-ac- talized with pneumonia in the United States: Incidence, quired pneumonia: An appraisal of recent epidemiology, and mortal- meta-analyses of clinical trials. J Thorac Dis. ity. Clin Infect Dis. 2017 Dec 2016 Mar; 8(3):E162-71. 1:65(11):1806-12. • Siemieniuk RAC et al. Corticosteroid thera- 2. Musher D et al. Communi- ty-acquired pneumonia: Review py for patients hospitalized with communi- article. N Engl J Med. 2014 Oct ty-acquired pneumonia: A systematic review 23;371:1619-28. and meta-analysis. Ann Intern Med. 2015 3. Wunderink R et al. Communi- Oct 6; 163:519 (http://dx.doi.org/10.7326/ ty-aquired pneumonia: Clinical practice. N Engl J Med. 2014 M15-0715). Feb 6;370:543-51. • Wan YD et al. Efficacy and safety of 4. Mandell L et al. Infectious corticosteroids for community-acquired pneu- Diseases Society America/Amer- ican Thoracic Society consensus monia: A systemic review and meta-analysis. guidelines on the management Chest. 2016 Jan;149(1):209-19. of community-acquired pneu- monia in adults. Clin Infect Dis. 2007;44:S27-72. 5. Wagner HN et al. The effect of event, or diarrhea) in patient with nonsevere CAP showed a significantly higher incidence of hyper- hydrocortisone upon the course of pneumococcal pneumonia treated with corticosteroids. glycemia in patients who received corticosteroids. treated with penicillin. Bull Johns Hopkins Hosp. 1956;98:197-215. The study in the American Journal of Emergen- 6. Polverino E et al. Systemic corticosteroids for communi- cy Medicine involved 10 trials involving more than Application of the data to our patients ty-acquired pneumonia: Reasons for use and lack of benefit on outcome. Respirology. 2013. Feb;18(2):263-71 (https://doi. 700 patients admitted with severe CAP and found The benefit of adjuvant corticosteroids is most org/10.1111/resp.12013). in-hospital mortality was cut in half (relative risk, clear in hospitalized patients with severe CAP. Re- 7. Stern A et al. Corticosteroids for pneumonia. Cochrane 0.49) and length of hospital stay was reduced cent, strong evidence supports decreased mortality, Database Syst Rev. 2017 Dec 13; 12:CD007720 (https://doi. when patients were treated with corticosteroids in decreased time to clinical stability, and decreased org/10.1002/14651858.CD007720.pub3). addition to standard antibiotic therapy.9 length of stay in our patient, with severe CAP, if 8. Briel M et al. Corticosteroids in patients hospitalized with community-acquired pneumonia: Systematic review and individ- In 2015, two randomized clinical trials, one treated with 20-60 mg of prednisone or equivalent ual patient data meta-analysis. Clin Infect Dis. 2018 Feb 1;66:346 in the Lancet and the other in JAMA, and a total daily dose for 3-7 days. For patients with non- (https://doi.org/10.1093/cid/cix801). meta-analysis in Annals of Internal Medicine as- severe CAP, we suggest taking a risk-benefit ap- 9. Wu W-F et al. Efficacy of corticosteroid treatment for severe sessed the impact of adjuvant corticosteroids in proach based on other comorbidities, as the risk for community-acquired pneumonia: A meta-analysis. Am J Emerg Med. 2017 Jul 15; [e-pub] (http://dx.doi.org/10.1016/j. the treatment of hospitalized patients with CAP. CAP-related rehospitalizations may be higher. ajem.2017.07.050). The Lancet study of 785 patients hospitalized For patients with underlying lung disease, spe- 10. Blum CA et al. Adjunct prednisone therapy for patients with with CAP of any severity found shortened time cifically chronic obstructive pulmonary disease community-acquired pneumonia: A multicentre, double-blind, randomised, placebo-controlled trial. Lancet 2015 Jan 18; [e-pub to clinical stability (3.0 vs. 4.4 days) as defined by (COPD) or reactive airway disease, we suggest a low ahead of print] (http://dx.doi.org/10.1016/S0140-6736[14]62447-8). stable vital signs, improved oral intake, and nor- threshold for adding corticosteroids. This approach 11. Torres A et al. Effect of corticosteroids on treatment failure malized mental status for greater than 24 hours is more anecdotal than data driven, though corti- among hospitalized patients with severe community-acquired when oral prednisone 50 mg for 7 days was added costeroids are a mainstay of treatment for COPD pneumonia and high inflammatory response: A randomized clin- 10 ical trial. JAMA 2015 Feb 17; 313:677 (http://dx.doi.org/10.1001/ to standard therapy. Patients in the treatment exacerbations and a retrospective analysis of more jama.2015.88). group were also discharged 1 day earlier com- than 20,000 hospitalized children with CAP and 12. Siemieniuk RAC et al. Corticosteroid therapy for patients pared with the placebo control group. wheezing revealed decreased length of stay with hospitalized with community-acquired pneumonia: A systematic The study in JAMA was small, with only 100 corticosteroid treatment.13 Furthermore, a number review and meta-analysis. Ann Intern Med. 2015 Oct 6;163:519 (http://dx.doi.org/10.7326/M15-0715). patients at three teaching hospitals in Spain, but of the studies described above included patients 13. Simon LH et al. Management of community-acquired pneu- found that patients hospitalized with severe CAP with COPD. Our threshold rises significantly in pa- monia in hospitalized children. Current Treat Options Peds (2015) and high inflammatory response based on elevat- tients with poorly controlled diabetes mellitus. 1:59 (https://doi:.org/10.1007/s40746-014-0011-3). ed C-reactive protein were less likely to experience a treatment failure, defined as shock, mechanical Quiz ventilation, death, or radiographic progression, when intravenous methylprednisolone 0.5 mg/kg Which of the following is FALSE regarding community-acquired pneumonia? was added to standard antibiotic therapy.11 A. CAP is the leading cause of infectious disease–related death in the United States. Finally, the meta-analysis in Annals of Inter- B. An excessive inflammatory cytokine response may contribute to the high mortality rate in CAP. nal Medicine assessed 13 randomized controlled C. Adjunctive steroid therapy has been shown to decrease mortality in all patients with CAP. placebo trials of 1,974 patients and found that D. Hyperglycemia occurs more frequently in patients receiving steroid therapy. adjuvant corticosteroids in a dose of 20-60 mg of E. Reasons to avoid adjunctive steroid therapy in CAP include low risk for mortality, poorly controlled prednisone or equivalent total daily dose signifi- diabetes, suspected viral or fungal etiology, and elevated risk for gastrointestinal bleeding. cantly lowered mortality in patients with severe CAP and incidence of respiratory distress syn- ANSWER: C. The patient population that may benefit most from the use of adjuvant corticoster- drome, and need for mechanical ventilation in all oids is poorly defined. However, in patients with severe pneumonia, the use of adjuvant steroids patients hospitalized with CAP.12 has been shown to decrease mortality, time to clinical stability, and length of stay. Importantly, nearly all of the described studies the-hospitalist.org | 19 | June 2019 CLINICAL In the Literature Clinician reviews of HM-centric research

By Gene Lambert, MD, MBA, FACP; Farrin A. Manian, MD, MPH; Adith Sekaran, MD; Hugo Torres, MD, MPH; and Amar Vedamurthy, MBBS, MS Division of Hospital Medicine, Massachusetts General Hospital, Boston

IN THIS ISSUE fective in the treatment of all types 36 mg, 99.6% confidence interval, of chronic localized pain. 6.5-24; P < .001), which exceeded 1. Compounded analgesic topical creams offer no benefit in treatment of CITATION: Brutcher RE et al. Com- the prespecified 10-mg threshold localized chronic pain pounded topical pain creams to for a minimal clinically important 2. Acetaminophen plus ibuprofen cut patient-controlled morphine after treat localized chronic pain. Ann difference (MCID). The difference total hip arthroplasty Intern Med. 2019;170(5):309-18. between acetaminophen-ibuprofen 3. New tetracycline antibiotic effective in community-acquired bacterial and ibuprofen monotherapy (20 mg pneumonia Acetaminophen plus vs. 26 mg) did not exceed the MCID, 4. New tetracycline antibiotic effective in acute bacterial skin and skin- 2 ibuprofen cut patient- and was not clinically meaningful. structure infections controlled morphine after total The differences in morphine con- 5. Adding mechanical to pharma prophylaxis does not cut DVT incidence hip arthroplasty sumption with full-strength acet- 6. Sepsis patients with hypothermia face greater mortality risk aminophen-ibuprofen compared to 7. Don’t delay antibiotic treatment in elderly patients with UTI CLINICAL QUESTION: Is the periop- half-strength acetaminophen-ibupro- 8. IV-to-oral antibiotics can benefit patients with MRSA bloodstream erative/early postoperative use of fen (28 mg) and ibuprofen compared infection acetaminophen-ibuprofen associat- to acetaminophen monotherapy 9. Andexanet alfa reverses factor Xa inhibitors ed with less patient-controlled mor- were not statistically significant. 10. MRSA decolonization reduces postdischarge infections phine administration after total hip Serious adverse events, the other arthroplasty? primary outcome, within 90 days BACKGROUND: The use of mul- after surgery (15% in the ibuprofen timodal non-opioid analgesics is a group and 11% in the acetamino- By Gene Lambert, MD, MBA, pain arm, a formulation containing common practice to minimize post- phen group, relative risk, 1.44; 97.5% FACP 10% ketamine, 6% gabapentin, 3% operative pain and opioid analgesic CI, 0.79-2.64; P = .18) did not differ Compounded analgesic diclofenac, 2% baclofen, 2% cyclo- use. There is limited high-quality between acetaminophen monother- 1 topical creams offer no benzaprine, and 2% lidocaine. Half evidence to confirm the synergistic apy and ibuprofen monotherapy. benefit in treatment of of the patients in each subgroup effect and safety of acetaminophen Secondary outcomes included statis- localized chronic pain received the compounded formu- and ibuprofen in the peripostoper- tically significant analgesia (lower lation and the other half received ative setting. The Paracetamol and pain scores) at rest and with mobili- CLINICAL QUESTION: Are com- placebo. NSAID in combination (PANSAID) zation at 24 hours in the acetamino- pounded topical creams effective The primary outcome was the trial investigated the analgesic effi- phen-ibuprofen group compared to analgesia for localized chronic pain? average pain cacy and safety of four multimodal the other groups. BACKGROUND: Federal health score at 1 month analgesic regimens after total hip An interesting observation was system programs, including TRI- follow-up, based arthroplasty. that acetaminophen-ibuprofen did CARE for military personnel, spent on self-recorded STUDY DESIGN: Multicenter, ran- not exceed the MCID compared $259 million in 2013 and $746 mil- arithmetic mean domized, blinded trial. to ibuprofen, which suggests that lion in 2014 for compounded anal- pain scores in the SETTING: A total of six hospitals in ibuprofen monotherapy may be a gesic medications despite a dearth preceding week. Denmark, which represented region- reasonable option for early postop- of efficacy data. The purpose of Secondary out- al and large university settings. erative analgesia. this trial was to evaluate the effi- comes included SYNOPSIS: A total of 559 patients BOTTOM LINE: Acetamino- cacy and functional impact of this Dr. Lambert mean worst pain who underwent total hip arthro- phen-ibuprofen reduced postop- class of medications for chronic over the past plasty were randomized to receive erative morphine use and had localized pain. week, functional improvement one of the following oral regimens: improved analgesia 24 hours after STUDY DESIGN: Randomized, dou- (assessed by validated Short-Form acetaminophen (1,000 mg) and ibu- total hip arthroplasty, and was ble-blind, parallel trial. 36 Health Survey scores), and satis- profen (400 mg), acetaminophen not associated with an increased SETTING: Walter Reed National Mil- faction (measured on a 1 to 5 Likert (1,000 mg) and placebo, ibuprofen 3-month risk of serious adverse itary Medical Center. scale) with the individual treat- (400 mg) and placebo, and half- events. SYNOPSIS: A total of 339 patients ment regimen. strength acetaminophen (500 mg) CITATION: Thybo KH et al. Effect with at least mild, chronic local- Patients had small improvements and ibuprofen (200 mg). One of the of combination of paracetamol ized pain were allocated to three in average pain scores at 1 month in regimens was initiated 1 hour be- (acetaminophen) and ibuprofen vs. subgroups of 133 patients based on the compounded formulation and fore surgery and continued every 6 either alone on patient-controlled pain type; neuropathic, nociceptive, placebo subgroups in all pain type hours for a total of 4 doses on the morphine consumption in the first or mixed pain. The patients in the categories. No significant differenc- first postoperative day. The mean 24 hours after total hip arthroplasty. neuropathic pain arm received a es were noted in the average pain age was 67 years, and half of the pa- The PANSAID randomized clinical compounded formulation contain- scores compared to baseline, func- tients were women. trial. JAMA. 2019;321(6):562-71. ing 10% ketamine, 6% gabapentin, tional improvement or satisfaction The median morphine consump- 0.2% clonidine, and 2% lidocaine; in in the compounded formulation and tion in the 24 hours after surgery Dr. Lambert is a hospital medicine the nociceptive pain arm, a formu- placebo groups of the total cohort or was significantly lower with clinician and addiction medicine lation containing 10% ketoprofen, in any of the subgroups. full-strength acetaminophen-ibu- specialist in the division of hospital 2% baclofen, 2% cyclobenzaprine, BOTTOM LINE: Compounded top- profen compared with acetamin- medicine at Massachusetts General and 2% lidocaine; and in the mixed ical analgesics are costly and inef- ophen monotherapy (20 mg vs. Hospital. June 2019 | 20 | The Hospitalist CLINICAL | In the Literature

By Farrin A. Manian, MD, MPH 85.1%). Mean duration of IV therapy respective drugs after at least 3 days By Adith Sekaran, MD New tetracycline antibiotic was 5.7 days, and the mean total of therapy. Adding mechanical to 3 effective in community- duration of therapy was 9.6 days Omadacycline was noninferior 5 pharma prophylaxis does acquired bacterial pneumonia in both groups. The frequency of to moxifloxacin with respect to not cut DVT incidence adverse events (primarily gastroin- early clinical response (84.8% vs. CLINICAL QUESTION: Is omadacy- testinal) was similar between the 85.5%, respectively) and posttreat- CLINICAL QUESTION: Does adding cline, a new tetracycline-class anti- two groups. ment clinical response rates (86.1% mechanical prophylaxis to phar- biotic, as effective as moxifloxacin Exclusion of the most severe CAP vs. 83.6%). Efficacy was similar for macological prophylaxis lower the in the treatment of community-ac- and immunocompromised patients methicillin-susceptible or methicil- incidence of deep-vein thrombosis quired bacterial pneumonia? limits generalizability of these re- lin-resistant Staphylococcus aureus, (DVT)? BACKGROUND: Community-ac- sults. the most common isolated patho- BACKGROUND: Critically ill pa- quired pneumonia (CAP) is a lead- BOTTOM LINE: Omadacycline gens. Frequency of adverse events tients have a high risk of venous ing cause of hospitalization and provides similar clinical benefit as (primarily gastrointestinal) was also thromboembo- death, particularly in the elderly. moxifloxacin in the treatment of se- similar in the two groups. Mean lism (VTE) during Omadacycline is a new once-daily lected patients with CAP. duration of IV therapy was 4.4 days, their hospital- tetracycline with in vitro activity CITATION: Stets R et al. Omada- and mean duration of oral therapy izations, and it against a wide range of CAP patho- cycline for community-acquired was 5.5 days in the omadacycline is standard of gens, including bacterial pneumonia. N Eng J Med. group. care to prophylax Streptococcus 2019;380:517-27. BOTTOM LINE: Omadacycline against this com- pneumoniae, provides similar clinical benefit as plication by either Staphylococcus New tetracycline antibiotic linezolid in the treatment of ABSS- pharmacological aureus, Hae- 4 effective in acute bacterial SIs. or mechanical Dr. Sekaran mophilus influen- skin and skin-structure CITATION: O’Riordan W et al. Omad- means. zae, and atypical infections acycline for acute bacterial skin and STUDY DESIGN: Prospective, ran- organisms, such skin-structure infections. N Eng J domized, controlled trial (Pneumatic as Mycoplasma CLINICAL QUESTION: Is omad- Med. 2019;380:528-38. Compression for Preventing Venous Dr. Manian pneumoniae, acycline, a new tetracycline-class Thromboembolism [PREVENT]). Legionella pneu- antibiotic, as effective as linezolid in Dr. Manian is a core educator faculty SETTING: Multicenter study involv- mophila, and Chlamydia pneumo- the treatment of acute bacterial skin member in the department of ing 20 ICUs in Saudi Arabia, Canada, niae. and skin-structure infections? medicine at Massachusetts General Australia, and India. STUDY DESIGN: Phase 3 random- BACKGROUND: Acute bacterial Hospital and an associate professor SYNOPSIS: The study monitored ized, double-blind, double-dummy, skin and skin-structure infections of medicine at Harvard Medical 2,003 medical and surgical ICU pa- placebo-controlled trial. (ABSSSIs) continue to account for School, Boston. tients on pharmacological throm- SETTING: Hospitalized patients substantial morbidity and health Continued on following page (98.8%) in non-ICU settings at 86 care burden, with the emergence of sites in Europe, North America, drug-resistant pathogens further South America, the Middle East, Af- complicating their management. rica, and Asia. Omadacycline is a new once-daily SYNOPSIS: The trial recruited 774 tetracycline with in vitro activity adults with three or more CAP against a wide range of causative symptoms (cough, purulent spu- agents of ABSSSI, including Strep- tum production, dyspnea, or pleu- tococcus pyogenes, Staphylococcus ritic chest pain) and at least two aureus (including methicillin-resis- abnormal vital signs, one or more tant strains, or MRSA), and Entero- clinical signs or laboratory findings coccus spp. associated with CAP, radiologically STUDY DESIGN: Phase 3, random- confirmed pneumonia, and a Pneu- ized, double-blind, double-dummy, monia Severity Index (PSI) of II, III, placebo-controlled trial. or IV (with higher class numbers SETTING: A total of 55 sites in the indicating a greater risk of death). United States, Peru, South Africa, Exclusion criteria included having and Europe. clinically significant liver or renal SYNOPSIS: The trial recruited 645 insufficiency or having an immu- adults with a qualifying ABSSSI nocompromised state. The patients (such as wound infection, celluli- were randomized to receive either tis or erysipelas, or major abscess) omadacycline or moxifloxacin with evidence of an inflammatory intravenously with the option response (white blood cell count at to switch to the oral preparation least 10,000 cells/mm3 or 4,000 cells/ Make 2020 your year. of the respective drugs after at mm3 and below, immature neutro- Applications are now open to all qualifying members least 3 days of therapy. Atypical phils at least 15%, lymphatic involve- organisms were implicated in 67% ment, or oral or rectal temperature of the hospital medicine team. of CAPS with known cause, while greater than 38.0° C or less than Apply by September 13, 2019 to qualify for an early decision notification. Streptococcus pneumoniae and 36.0° C). Exclusion criteria included Haemophilus influenzae were impli- infections associated with chronic cated in 20% and 12%, respectively. skin lesions and clinically signifi- Omadacycline was noninferior to cant liver or renal insufficiency or moxifloxacin with respect to early immunocompromised state. All pa- hospitalmedicine.org/fellows clinical response (81.1% vs 82.7%, tients received either omadacycline respectively) and posttreatment or linezolid IV with the option to clinical response rates (87.6% vs. switch to the oral preparation of the the-hospitalist.org | 21 | June 2019 CLINICAL | In the Literature

Continued from previous page shock). The median age was 73 years boprophylaxis (unfractionated or with a median APACHE II and SOFA low-molecular-weight heparin) scores of 22 and 9, respectively. after receiving either adjunctive Core temperatures were measured pneumatic compression or phar- on admission to ICU with patients macological thromboprophylaxis categorized into three arms: tem- alone. The primary outcome was perature under 36° C (hypothermic), incident (newly diagnosed) prox- temperature 36°-38° C, and febrile imal lower-limb DVT detected by patients with temperature greater twice-weekly venous ultrasonog- than 38° C. Of studied patients, 11.1% raphy until ICU discharge, death, were hypothermic on presentation. attainment of full mobility, or trial These patients were older, sicker day 28, whichever occurred first. (higher APACHE/SOFA scores), had Key secondary outcomes included lower body mass indexes, and had the occurrence of any lower-limb higher prevalence of septic shock DVTs and pulmonary embolism. In- than did the febrile patients. Hy- termittent pneumatic compression pothermic patients fared worse in was used a median of 22 hours daily. every clinical outcome measured The incidence of proximal lower – in-hospital mortality, 28-day mor- limb DVT did not differ in the two tality, ventilator-free days, ICU-free groups and was relatively low (4%) days, length of hospital stay, and in the control group. There were likelihood of discharge home. The also no differences in the groups in the composite VTE, death at 28 days, Short Takes or any other secondary outcomes studied. The main limitation of the study Cognitively impaired patients was the low incidence of primary less likely to be readmitted outcomes in the control group, with care transitions program which reduced the power of the Retrospective cohort analysis of study. the Mayo Clinic Care Transitions BOTTOM LINE: Based on the PRE- Program for patients at risk of VENT trial, adjunctive intermittent readmission shows that cogni- pneumatic compression provided no tively impaired patients were additional benefit to pharmacologi- less likely to be readmitted than cal prophylaxis in the prevention of were cognitively intact ones. The incident proximal lower-limb DVT. authors were unable to identify CITATION: Arabi Y et al. Adjunctive which individual program compo- THE ONLY intermittent pneumatic compres- nents were most important in HOSPITALIST-FOCUSED sion for venous thromboprophy- preventing readmission laxis. N Eng J Med. 2019 Feb 18. doi: CITATION: Thorsteinsdottir B et 10.1056/NEJMoa1816150. al. Care transitions program for LEADERSHIP PROGRAM high-risk frail older adults is most Sepsis patients with beneficial for patients with cogni- VISIT SHMLEADERSHIPACADEMY.ORG 6 hypothermia face greater tive impairment. J Hosp Med. mortality risk 2019. doi: 10.12788/jhm.3112. CLINICAL QUESTION: Is lower Improve diagnostic accuracy body temperature associated with by involving multiple lower rates of sepsis bundle imple- physicians mentation, sicker patients, and poor- A cross-sectional study using er outcomes? data from the Human Diagno- BACKGROUND: Fevers (like other sis Project (Human Dx) showed vital sign abnormalities) often trig- that the collective intelligence of ger interventions from providers. attending physicians, residents, However, hypothermia (temperature fellows, and medical students under 36° C) may also be associated improved diagnostic accuracy, with higher mortality. compared with that of individual STUDY DESIGN: Retrospective physicians. However, the cases in subanalysis of a previous study (Fo- Human Dx may not be represent- cused Outcome Research on Emer- ative of the scenarios encoun- gency Care for Acute respiratory tered in day-to-day practice, and distress syndrome, Sepsis and Trau- the subject merits further study. ¨ ma [FORECAST]). CITATION: Barnett ML et al. SETTING: Adult patients with se- Comparative accuracy of diag- vere sepsis based on Sepsis-2 in 59 nosis by collective intelligence of ICUs in Japan. multiple physicians vs individual SYNOPSIS: The study involved 1,143 physicians. JAMA Netw Open. patients admitted to ICUs with 2019;2(3):e190096. severe sepsis (62.6% with septic June 2019 | 22 | The Hospitalist CLINICAL | In the Literature odds ratio of in-hospital mortality presentation with symptoms, 0.2% least one positive blood culture for Short Takes for hypothermic patients, compared developed BSI within 60 days versus MRSA who had not yet completed with reference febrile patients, 2.2% of patients in whom antibiot- their antibiotic course at the time Febuxostat associated with was 1.76 (95% CI, 1.14-2.73). Patients ics were delayed and 2.9% among of discharge during the index hos- increased CV, all-cause with hypothermia were also sig- patients not prescribed antibiotics. pitalization but were sufficiently mortality compared with nificantly less likely to receive the After adjustment for comorbidities, stable to complete outpatient anti- allopurinol entire 3-hour resuscitation bundle, sex, and socio- biotic treatment. Of this cohort, 70 The Cardiovascular Safety of including broad-spectrum antibiot- economic status, patients were switched to oral an- Febuxostat and Allopurinol in ics (56.3%) versus 60.8% of patients patients in whom tibiotic therapy on discharge, while Patients With Gout and Cardio- with temperature 36-38° C and 71.1% antibiotics were the rest received OPAT. The primary vascular Morbidities (CARES) trial for febrile group (P = .003). deferred had a outcome was clinical failure, a 90- was a multicenter, randomized, BOTTOM LINE: Hypothermia in 7.12-fold greater day composite measure of MRSA double-blind cardiovascular patients with severe sepsis is asso- odds of BSI, com- bloodstream infection recurrence, outcomes trial conducted in ciated with a significantly higher pared with the deep MRSA infection, or all-cause 6,190 patients with gout treated disease severity, mortality risk, and immediate-anti- mortality. The most commonly with either febuxostat or allopu- lower implementation of sepsis Dr. Torres biotic group. BSIs used oral antibiotics were linezolid, rinol. bundles. More emphasis on earlier were more com- trimethoprim/sulfamethoxazole, Febuxostat did not increase identification and treatment of this mon among men and older patients. and clindamycin, all with high bio- the risk of the composite prima- specific patient population appears All-cause mortality, a secondary availability. Endovascular infection ry outcome of major adverse needed. outcome, was 1.16-fold higher with was present in 21.5% of the study cardiovascular events, but it CITATION: Kushimoto S et al. Im- deferred antibiotics and 2.18 times population. After propensity score was associated with a significant pact of body temperature abnor- higher with no antibiotics. adjustment for covariates, patients increase in cardiovascular deaths malities on the implementation While the cohort studied was very who received oral antibiotics had a and all-cause mortality. The FDA of sepsis bundles and outcomes in large, a causal relationship cannot nonsignificant reduction in the rate issued a Drug Safety Commu- patients with severe sepsis: A retro- be firmly established in this obser- of clinical failure (hazard ratio, 0.379; nication in February 2019 and spective sub-analysis of the focused vational study. Also, researchers 95% CI, 0.131-1.101). added a Boxed Warning to the outcome of research of emergency were unable to include laboratory Limitations of the study includ- prescription information. care for acute respiratory distress data, such as urinalysis and culture, ed its observational design with CITATION: White WB et al. syndrome, sepsis and trauma study. in their analysis. potential for significant residual Cardiovascular safety of febux- Crit Care Med. 2019 May;47(5):691-9. BOTTOM LINE: Delayed pre- confounding despite the propen- ostat or allopurinol in patients scription of antibiotics for elderly sity score–adjusted analysis, its with gout. N Eng J Med. Dr. Sekaran is a hospitalist at patients presenting with UTI in single-center setting, the low fre- 2018;378:1200-10. Massachusetts General Hospital. primary care settings was associated quency of endovascular infections, with higher rates of BSI and death. and the uncertainty in how the loss Follow-up of incidental high- By Hugo Torres, MD, MPH CITATION: Gharbi M et al. Antibiotic of patients to follow-up might have risk nodules on CT pulmonary Don’t delay antibiotic management of urinary tract infec- affected the results. angiography 7 treatment in elderly patients tion in elderly patients in primary BOTTOM LINE: Selected patients This was a retrospective cohort with UTI care and its association with blood- with MRSA BSI may be successfully study examining patients with stream infections and all-cause treated with sequential IV-to-oral incidental pulmonary nodules CLINICAL QUESTION: Is there mortality: Population-based cohort antibiotic therapy. diagnosed when emergen- an association between delayed study. BMJ. 2019 Feb;364:1525. CITATION: Jorgensen SCJ et al. cy department or hospitalized antibiotic treatment and adverse Sequential intravenous-to-oral patients underwent CT pulmo- outcomes in elderly patients with IV-to-oral antibiotics can outpatient antibiotic therapy for nary angiography (CTPA). Only suspected or confirmed urinary 8 benefit patients with MRSA MRSA bacteraemia: One step clos- a quarter of the patients with tract infections (UTIs)? bloodstream infection er. J Antimicrob Chemother. 2019 pulmonary nodules received BACKGROUND: If left untreated, Feb;74(2):489-98. explicit follow-up instructions, UTIs may lead to severe complica- CLINICAL QUESTION: Is sequential with less than one-half of those tions. Although campaigns aimed IV-to-oral antibiotic therapy as ef- Dr. Torres is a hospitalist at patients taking the next appro- at decreasing unnecessary prescrip- fective as outpatient parenteral an- Massachusetts General Hospital. priate step. Overall, follow-up for tions have reduced the number of tibiotic therapy (OPAT) in patients pulmonary nodules was poor. antibiotic prescriptions for UTI, with MRSA BSI? By Amar Vedamurthy, MBBS, CITATION: Kwan JL et al. Follow a concurrent rise in the rates of BACKGROUND: Methicillin-resis- MS up of incidental high-risk pulmo- gram-negative bloodstream infec- tant Staphylococcus aureus blood- Andexanet alfa reverses nary nodules on computed tions (BSIs) has also been observed. stream infections carry a high risk 9 factor Xa inhibitors tomography pulmonary angi- STUDY DESIGN: Retrospective, of morbidity and relapse with most ography at care transitions. J population-based cohort study with published guidelines recommending CLINICAL QUESTION: Does an- Hosp Med. 2019 Feb 20. doi: data compiled from primary care prolonged courses of IV antibiotics dexanet alfa reverse acute major 10.12788/jhm.3128. records from 2007 to 2015 linked to to ensure complete clearance of bleeding associated with factor Xa hospital episode statistics and death the infection. However, long-term inhibitors? records. IV antibiotic therapy may also be BACKGROUND: Factor Xa inhibi- the anticoagulation effects of factor SETTING: General practices in En- costly and is not without its own tors have become increasingly popu- Xa inhibitors. gland. complications. An equally effective lar in the treatment and prevention STUDY DESIGN: A prospective, SYNOPSIS: The investigators ana- IV-to-oral antibiotic therapy would of thrombotic events, but the lack of open-label, single-group cohort lyzed 312,896 UTI episodes among be welcome. specific reversal agents in the event study. 157,264 unique patients (65 years STUDY DESIGN: Retrospective co- of life-threatening or uncontrolled SETTING: An industry-sponsored, of age or older) during the study hort study. bleeding may limit their use. Andex- multicenter study. period. Exclusion criteria included SETTING: A single academic center anet alfa is a new Food and Drug SYNOPSIS: The study evaluated asymptomatic bacteriuria and com- in the United States. Administration–approved reversal 352 adult patients who had acute plicated UTI. Of 271,070 patients who SYNOPSIS: The investigators re- agent which rapidly reduces anti– major bleeding (such as intracrani- received antibiotics on the day of viewed data from 492 adults with at factor Xa activity, thereby reversing Continued on following page the-hospitalist.org | 23 | June 2019 CLINICAL | In the Literature

Continued from previous page Xa activity and hemostasis. The cal-site infections, recurrent skin in the education group and 6.3% in al hemorrhage [64%] or GI bleeding sponsor is planning to conduct a infections, and infections in ICU. the decolonization plus education [26%] within 18 hours after admin- randomized trial with FDA guidance However, there is sparsity of data on group, with 30% reduction in the istration of a factor Xa inhibitor, in the near future. the efficacy of routine decoloniza- risk of infection (HR, 0.70; 95% CI, including apixaban, rivaroxaban, or BOTTOM LINE: Andexanet alfa is tion of MRSA carriers after hospital 0.51-0.99; number needed to treat edoxaban). Efficacy was assessed an FDA-approved agent and appears discharge. to prevent one infection, 30). The in 254 patients who met criteria effective in achieving hemostasis in STUDY DESIGN: Multicenter, ran- decolonization group also had a for severe bleeding and elevated patients with a factor Xa inhibitor– domized, unblinded controlled trial. lower hazard of clinically judged baseline anti–factor Xa activity. associated major acute bleeding. SETTING: A total of 17 hospitals and infection from any cause (HR, 0.83; Patients were administered a bolus CITATION: Connolly SJ et al. Full seven nursing homes in Southern 95% CI, 0.70-0.99) and infection-re- dose of andexanet alfa followed study report of andexanet alfa for California. lated hospitalization (HR, 0.76; 95% by a 2-hour infusion. The median bleeding associated with factor Xa SYNOPSIS: The study included 2,121 CI, 0.62-0.93). anti–factor Xa activity reduced by inhibitors. N Eng J Med. 2019 Feb 7. inpatients hospitalized within the Limitations of the study include 92% each among patients receiving doi: 10.1056/NEJMoa1814051. previous 30 days and found to be unblinded intervention, missing of apixaban or rivaroxaban. The ma- MRSA carriers. Patients were ran- milder infections that might not jority (82%) of evaluable patients MRSA decolonization domized to education only (1,063) have required hospitalization, and achieved excellent or good hemo- 10reduces postdischarge or decolonization plus education frequent insufficient documen- stasis at 12 hours after andexanet infections (1,058), with both groups followed tation in charts for events to be alfa administration, which com- for 12 months after discharge. De- deemed infection according to the pares favorably with the hemostat- CLINICAL QUESTION: Does post- colonization consisted of 4% rinse- CDC criteria. ic efficacy of 72% observed with discharge decolonization of MRSA off chlorhexidine for daily bathing BOTTOM LINE: Decolonization of prothrombin complex concentrate carriers lead to lower future risk of or showering, 0.12% chlorhexidine MRSA carriers post discharge may used to reverse anticoagulation MRSA infection? mouthwash twice daily, and 2% lower MRSA-related infections and in patients treated with vitamin BACKGROUND: MRSA carriers nasal mupirocin twice daily. The infections more than hygiene educa- K antagonists. Of patients in the are at higher risk of infection and primary outcome was MRSA infec- tion alone. study, 10% experienced a throm- rehospitalization after hospital tion as defined by the CDC. Sec- CITATION: Huang SS et al. Decol- botic event during the 30-day fol- discharge. Education regarding hy- ondary outcomes included MRSA onization to reduce postdischarge low-up period, and 14% died. giene, environmental cleaning, and infection based on clinical judg- infection risk among MRSA carriers. Limitations of the study include decolonization of MRSA carriers ment, infection from any cause, and N Eng J Med. 2019;380:638-50. lack of a control group and ab- have been used as possible preven- infection-related hospitalization. sence of a significant relationship tive strategies. Decolonization has Per protocol analysis showed that Dr. Vedamurthy is a hospitalist at between a reduction in anti–factor been effective in reducing surgi- MRSA infection occurred in 9.2% Massachusetts General Hospital.

In pain treatment, racial bias common among physician trainees Race-based decision making observed

By Kari Oakes ology, physical exam findings, and pain intensity SES, dividing respondents into low (less than MDedge News by self-report. $38,000), medium ($38,000-$75,000), and high REPORTING FROM APS 2019 After viewing the videos and reading the vi- (greater than $75,000) SES categories. gnettes, participating clinicians were asked to use Demonstrated bias based on socioeconomic MILWAUKEE – More than 40% of white physician a 0-100 visual analog scale to report their likeli- status was common, and similar across levels of trainees demonstrated racial bias in medical deci- hood of referring patients to a pain specialist or provider SES, at 41%, 43%, and 38% for low, medi- sion making about treatment of low back pain, as to physical therapy and of recommending opioid um, and high SES residents and fellows, respec- did 31% of nonwhite trainees. However, just 6% of or nonopioid analgesia. tively. However, the disconnect between reported white residents and fellows, and 10% of the non- “Next, they rated the degree to which they and demonstrated bias that was seen with race white residents and fellows, reported that patient considered different sources of patient infor- was not seen with SES bias, with 43%-48% of race had factored into their treatment decisions mation when making treatment decision,” Ms. providers in each SES group reporting that they in a virtual patient task. Grant and her coauthors wrote. Statistical anal- had factored patient SES into their treatment de- The 444 medical residents and fellows who par- ysis “examined the extent to which providers cision making. ticipated viewed video vignettes presenting 12 vir- demonstrated statistically reliable treatment “These results suggest that providers have low tual patients who presented with low back pain, differences across patient race and SES.” These awareness of making different pain treatment wrote Alexis Grant of Indiana University–Purdue findings were compared with how clinicians decisions” for black patients, compared with deci- University Indianapolis and her colleagues. In a reported they used patient race and SES in deci- sion making for white patients, Ms. Grant and her poster presentation at the scientific meeting of sion making. colleagues wrote. “Decision-making awareness the American Pain Society, Ms. Grant, a doctoral Demonstrated race-based decision making did not substantially differ across provider race student in clinical psychology, and her collabora- occurred for 41% of white and 31% of nonwhite or SES.” She and her collaborators called for more tors explained that participants agreed to view a clinicians. About two-thirds of providers (67.3%) research into whether raising awareness about series of 12 videos of virtual patients. were white, and of the remainder, 26.3% were demonstrated racial bias in decision making can The videos presented male and female virtual Asian, 4.4% were classified as “other,” and 2.1% improve both racial and socioeconomic gaps in patients who were black or white and who had were black. The respondents were aged a mean pain care. jobs associated with low or high socioeconomic 29.7 years, and were 42.3% female. The authors reported funding from the Nation- status (SES). Information in text vignettes accom- In addition, Ms. Grant and her coauthors es- al Institutes of Health. They reported no conflicts panying the videos included occupation, pain eti- timated provider SES by asking about parental of interest. June 2019 | 24 | The Hospitalist NEWS Measles complications in the U.S. unchanged in posteradication era

By Ted Bosworth and Prevention – which reported 86 confirmed MDedge News cases of measles in 2000 – was referring to a tech- REPORTING FROM SID 2019 nical definition of no new endemic or continuous transmissions in the previous 12 months. It was CHICAGO – An evaluation of the measles threat expected that a modest number of cases of this in the modern era gives no indication that the reportable disease would continue to accrue for risk of complications or death is any different an infection that remains common elsewhere in than it was before a vaccine became available, ac- the world. cording to an analysis of inpatient complications “Worldwide there are about 20 million cases between 2002 and 2013. of measles annually with an estimated 100,000 In 2000, measles was declared eliminated in the deaths attributed to this cause,” said Dr. Chovati- United States, but for those who have been in- ya, who is a dermatology resident at Northwest- fected since that time, the risk of serious compli- ern University, Chicago. cations and death has not diminished, noted Raj In the United States, posteradication infection Chovatiya, MD, PhD, in a session at the annual rates remained at low levels for several years but meeting of the Society for Investigative Derma- were already rising from 2002 to 2013, when Dr. tology. Chovatiya and his coinvestigators sought to de- By eliminated, the Centers of Disease Control scribe the incidence, associations, comorbidities,

and outcomes of hospitalizations for measles. wald he N C

Toward the end of the period the researchers i

were examining the incidence rates climbed more F. e z ei N

steeply. h . “So far this year, 764 CDC cases of measles r C/ d d

[were] reported. That is the most we have seen in C the U.S. since 1994,” Dr. Chovatiya said. Based on his analysis of hospitalizations from So far this year, 764 CDC cases of 2002 to 2013, the threat of these outbreaks is “ no different then that before the disease was measles [were] reported. That is the declared eliminated or before a vaccine became most we have seen in the U.S. since available. 1994. The cross-sectional study was conducted with data from the Nationwide Inpatient Sample, an ” all-payer database that is considered to be a rep- 3.5 days) and slightly but significantly higher di- resentative of national trends. rect costs ($18,907 vs. $18,474). Characteristic of measles, the majority of the “I want to point out that these are just direct 582 hospitalizations evaluated over this period inpatient costs,” Dr. Chovatiya said. Extrapolating occurred in children aged between 1 and 9 years. from published data about indirect expenses, he The proportion of patients with preexisting said that the total health cost burden “is abso- chronic comorbid conditions was low. Rather, lutely staggering.” “most were pretty healthy” prior to admission, Previous studies have suggested that about 25% according to Dr. Chovatiya, who said that the of patients with measles require hospitalization majority of admissions were from an emergency and 1 in every 1,000 patients will die. The data col- department. lected by Dr. Chovatiya support these often-cited

ews Measles, which targets epithelial cells and figures, indicating that they remain unchanged in depresses the immune system, is a potentially the modern era. edge N

/M d serious disease because of its ability to produce This new set of data emphasizes the need to h T complications in essentially every organ of the redouble efforts to address the reasons for the

oswor body, including the lungs, kidneys, blood, and cen- recent outbreaks, particularly insufficient pene- ed B T tral nervous system. Consistent with past studies, tration of vaccination in many communities. Dr. Raj Chovatiya the most common complication in this series was The vaccine “is inexpensive, extremely effec- pneumonia, observed in 20% of patients. The list tive, and lifesaving,” said Dr. Chovatiya, making of other serious complications identified in this the point that all of the morbidity, mortality, and Attempting to provide perspective of study period, including encephalitis and acute re- costs he described are largely avoidable. the measles threat and the impact nal failure, was long. Attempting to provide perspective of the mea- of the vaccine, Dr. Chovatiya cited “We observed death in 4.3% of our 582 cases, or sles threat and the impact of the vaccine, Dr. about 25 cases,” reported Dr. Chovatiya. He indi- Chovatiya cited a hypothetical calculation that a hypothetical calculation that cated that this is a high percentage among a pop- 732,000 deaths from measles would have been 732,000 deaths from measles would ulation composed largely of children who were expected in the United States among the pool well before hospitalization. of children born between 1994 and 2013 had no have been expected in the United The mortality rate from measles was numer- vaccine been offered. Again, most of these deaths States among the pool of children ically but not statistically higher than that of would have occurred in otherwise healthy chil- overall hospital admissions during this period, dren. born between 1994 and 2013 had no but an admission for measles was associated with Dr. Chovatiya reported no potential conflicts of vaccine been offered. significantly longer average length of stay (3.7 vs. interest. the-hospitalist.org | 25 | June 2019 Make your next smart move. Visit shmcareercenter.org.

HOSPITALISTS/ NOCTURNISTS NEEDED IN SOUTHEAST LOUISIANA

DAYTIME & NIGHTTIME OchsnerOchsner Health System is seeking physicians toto join our HOSPITALISTS hospitalist team. BC/BE Internal Medicine and Family Medicine physicians are welcomed to apply. Highlights of our opportunities are: Long Island, NY. NYU Winthrop Hospital, a 591-bed, university-affiliated medical center and an American College  Hospital Medicine was established at Ochsner in 1992. We have a stable 50+ member of Surgeons (ACS) Level 1 Trauma Center based in Western group Nassau County, NY is seeking BC/BE internists for academic Hospitalist positions.  7 on 7 off block schedule with flexibility  Dedicated nocturnists cover nights Ideal candidates will have exemplary clinical skills, a strong  interest in teaching house staff and a long term commitment Base plus up to 45K in incentives to inpatient medicine. Interest in research and administration  Average census of 14-18 patients a plus. Salaried position with incentive, competitive benefits package including paid CME, malpractice insurance and vacation.  E-ICU intensivist support with open ICUs at the community hospitals  EPIC medical record system with remote access capabilities DRIVEN TO BE  Dedicated RN and Social Work Clinical Care Coordinators Interested candidates, please  email CV and cover letter to: the best. Community based academic appointment [email protected]  The only Louisiana Hospital recognized by US News and World Report Distinguished or fax to: (516) 663-8964 Hospital for Clinical Excellence award in 4 medical specialties Ph: (516) 663-8963 Attn: Vice Chairman, Dept of Medicine-Hospital Operations  Co-hosts of the annual Southern Hospital Medicine Conference An EOE m/f/d/v  We are a medical school in partnership with the University of Queensland providing clinical training to third and fourth year students NYU Winthrop Hospital is located in the heart of Nassau  County in suburban Long Island, 30 miles from NYC and Leadership support focused on professional development, quality improvement, and just minutes from LI’s beautiful beaches.

 Opportunities for leadership development, research, resident and medical student teaching  Skilled nursing and long term acute care facilities seeking hospitalists and mid-levels with an interest in geriatrics Med/Peds Hospitalist Opportuniti es Available  Paid malpractice coverage and a favorable malpractice environment in Louisiana Join the Healthcare Team at  Generous compensation and benefits package Berkshire Health Systems Berkshire Health Systems is currently seeking BC/BE Med/Peds Ochsner Health System is Louisiana’s largest non-profit, academic, healthcare system. physicians to join our comprehensive Hospitalist Department Driven by a mission to Serve, Heal, Lead, Educate and Innovate, coordinated clinical and • Day and Nocturnist positions hospital patient care is provided across the region by Ochsner’s 29 owned, managed and • Previous Med/Peds Hospitalist experience is preferred affiliated hospitals and more than 80 health centers and urgent care centers. Ochsner is • Leadership opportunities available orld Report as a “Best Hospital” Located in Western Massachusetts Berkshire Medical Center is the across four specialty categories caring for patients from all 50 states and more than 80 region’s leading provider of comprehensive health care services countries worldwide each year. Ochsner employs more than 18,000 employees and over • Comprehensive care for all newborns and pediatric inpatients including: o Level Ib nursery 1,100 physicians in over 90 medical specialties and subspecialties, and conducts more than o 7 bed pediatrics unit 600 clinical research studies. For more information, please visit ochsner.org and follow us on o Care for pediatric patients admitted to the hospital Twitter and Facebook. • Comprehensive adult medicine service including: o 302-bed community teaching hospital with residency programs Interested physicians should email their CV to [email protected] o Geographic rounding model or call 800-488-2240 for more information. o A closed ICU/CCU o A full spectrum of Specialties to support the team Reference # SHM2017. o A major teaching affi liate of the University of Massachusetts Medical School and University of New England College of Osteopathic Medicine Sorry, no opportunities for J1 applications. • 7 on/7 off 12 hour shift schedule We understand the importance of balancing work with a healthy personal lifestyle Ochsner is an equal opportunity employer and all qualified applicants will receive consideration for • Located just 2½ hours from Boston and New York City employment without regard to race, color, religion, sex, national origin, sexual orientation, disability • Small town New England charm status, protected veteran status, or any other characteristic protected by law • Excellent public and private schools • World renowned music, art, theater, and museums • Year round recreational activities from skiing to kayaking, this is an ideal family location. Berkshire Health Systems offers a competitive To learn more, visit www.the-hospitalist.org and salary and benefi ts package, including relocation. click “Advertise” or contact Interested candidates are invited to contact: Heather Gonroski • 973-290-8259 • [email protected] or Liz Mahan, Physician Recruitment Specialist, Berkshire Health Systems 725 North St. • Pittsfield, MA 01201 • (413) 395-7866. Linda Wilson • 973-290-8243 • [email protected] Applications accepted online at www.berkshirehealthsystems.org

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

Joy. Make it part of your career.

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

We currently have opportunities for hospitalists and intensivists at hospitals and skilled nursing practices across the country. Some with sign-on bonuses up to $100,000! GROW YOUR PHYSICIAN CAREER WITH US • Hospitalist Opportunities •

Join our dedicated team of physicians providing outstanding care at St. Luke’s University Health Network! We have opportunities available at the following locations:

• PCP/Hospitalist Blend, Schuylkill County • Hospitalist Float Position • Full Time Day Hospitalist, Miners Campus • Full Time Day Hospitalist, Monroe Campus • Full Time Day Hospitalist, Quakertown Campus • Full Time Day Hospitalist, Sacred Heart Campus • Full Time Day Hospitalist, Allentown Campus • Full Time Day Hospitalist, Orwigsburg, PA (Brand new hospital campus joining our Network!) To learn more about our Hospitalist program, please visit www.slhn.org/hospitalistcareer

In joining St. Luke’s you’ll enjoy:

• A unique and supportive culture • Unlimited potential for career growth • A collaborative, team oriented approach that serves our community and each other • Attractive location stipends for certain campus positions • Loan repayment program – up to $100,000 • Substantial compensation and a rich benefits package, including malpractice California insurance, health and dental insurance, & CME allowance • Fresno • Redding • San Jose • Work/life balance in a vibrant community • Modesto • San Diego • San Mateo • Teaching, research, quality improvement and strategic development opportunities Illinois Missouri Oregon • Belleville • St. Louis • Eugene • Greenville For more information please call: Interested in travel? Check out our Reserves Program. Jillian Fiorino Physician Recruiter 484-526-3317 Future leader? [email protected] Apply for our Administrative Fellowship.

We proudly sponsor visa candidates!

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

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

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

FIND YOUR PATH As a nationwide network of world-class clinicians, mentors and industry thought leaders, TeamHealth offers the highest quality staffing, administrative support and management across the continuum of care.

TeamHealth hospitalists enjoy work-life balance with flexible scheduling options, career growth with one of the nation’s leaders in clinical integration and autonomy in their practice with opportunities to provide care in outstanding hospitals nationwide.

Join our team teamhealth.com/join or call 855.879.3153

Hospitalist Opportunities with Penn State Health

Penn State Health is a multi-hospital health system serving patients and communities across central Hospitalist Pennsylvania. We are seeking IM/FM trained physicians interested in joining the Penn State Health Bassett Healthcare Network, a progressive health care family in various settings within our system. network in Central New York and major teaching affiliate of What We’re Offering: Columbia University, is seeking a BC/BE Hospitalist to serve • Community Setting Hospitalist opportunities (Lancaster and Berks County positions) our patient population in Central New York. • We’ll foster your passion for patient care and cultivate a collaborative environment rich with diversity • 7 on/7 off Schedule • Highly Ranked Schools • Commitment to patient safety in a team approach model • Closed ICU • Visa Support • Experienced hospitalist colleagues and collaborative • Group Employed model • Stress Free Commute leadership • Salary commensurate with qualifications • Full Benefits • Fully Integrated EMR • Relocation Assistance Nestled in the foothills of the Adirondack and Catskill What We’re Seeking: Mountains, Bassett Medical Center is located in • Internal Medicine or Family Medicine trained Cooperstown, New York, a beautiful resort village on • Ability to acquire license in the State of Pennsylvania Otsego Lake. Home to the National Baseball Hall of Fame • Must be able to obtain valid federal and state narcotics and Museum, the Glimmerglass Opera Company, and the certificates Fenimore Art Museum, the area also boasts many cultural • Current American Heart Association BLS and ACLS and four season recreational advantages including theater, certification required • BE/BC in Family Medicine or Internal Medicine (position dependent) music, museums, golf, sailing, hiking, and skiing. No J1 visa waiver sponsorships available For confdential consideration, please contact: What the Area Offers: Joelle Holk, Medical Staff Recruitment Penn State Health is located in Central Pennsylvania. Our local neighborhoods boast a reasonable cost of living whether you prefer a phone: 607-547-6982; fax: 607-547-3651: more suburban setting or thriving city rich in theater, arts, and culture. Our surrounding communities are rich in history and offer email: [email protected] an abundant range of outdoor activities, arts, and diverse experiences. We’re conveniently located within a short distance to major or visit our web-site at www.experiencebassett.org cities such as Philadelphia, Pittsburgh, NYC, Baltimore, and Washington DC. Bassett Medical Center provides equal employment opportunities (EEO) to all For more information please contact: Heather J. Peffley, PHR FASPR, Penn State Health Physician Recruiter employees and applicants for employment without regard to race, color, religion, [email protected] creed, sex (including pregnancy, childbirth, or related condition), age, national origin or ancestry, citizenship, disability, marital status, sexual orientation, gender identity or expression (including transgender status), or genetic predisposition Penn State Health is committed to affirmative action, equal opportunity and the diversity of its workforce. or carrier status, military or veteran status, familial status, status a victim of Equal Opportunity Employer – Minorities/Women/Protected Veterans/Disabled. domestic violence, or any other status protected by law.

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

Live. Hospitalists and Nocturnists Opportunities Available

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

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

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

UPMCPinnacle.com/Providers

UPMC Pinnacle is an Equal Opportunity Employer. EOE

Employment Opportunity in the Beautiful Adirondack Mountains of Northern New York Seeking Changemakers ICU Hospitalist/Nocturnist CHA Everett Hospital Cambridge Health Alliance (CHA) is a well-respected, nationally Current Opening for a full-time, Join Our Hospitalist Team recognized and award-winning public healthcare system, which receives Hospital Employed Hospitalist. This opportunity recognition for clinical and academic innovations. Our system is comprised of three hospital campuses in Cambridge, Somerville and Everett with provides a comfortable 7 on/7 off schedule, additional outpatient clinic locations throughout Boston’s Metro North allowing ample time to enjoy all that the Region. CHA is an academic affiliate of both Harvard Medical School (HMS) Adirondacks have to offer! and Tufts University School of Medicine. We are a clinical affiliate of Beth Israel Deaconess Medical Center. Come live where others vacation! CHA is recruiting for an ICU Hospitalist/Nocturnist to cover Everett Hospital. • Position requires PM shifts (7p-7a) plus weekend day shifts • Convenient schedules • Lewiston, Idaho is To ensure a work-life Work collaboratively with CHA’s intensivist MDs to round on inpatients • Competitive salary & benefits within the CHA Everett Hospital ICU a charming town balance, we promise • Unparalleled quality of life • Cross coverage of med/surg inpatient unit included as part of clinical perfect for enjoying a 7on/7off stable • Family friendly community responsibility (10% of total FTE) the outdoors, as well and predictable • • Excellent schools Applicants should be comfortable with procedures including central as the city. schedule. lines, vent management, intubation, etc. • Nearby Whiteface • Internal training and maintenance program exists to assist in Mountain ski resort certification of these skills competencies • Home of the 1932 & 1980 • Academic appointment is available commensurate with medical school Winter Olympics and current criteria Olympic Training Center Applicants should be trained and Board Certified in Internal Medicine or • Annual lronman Competition Family Medicine and possess excellent clinical and communication skills • World Cup Bobsled and FT benefits packages In addition to plus a demonstrated commitment to CHA’s multicultural, underserved Ski Events include health above-market comp, patient population. • Abundant arts community insurance, dental, we reimburse travel, At CHA, we have a supportive and collegial clinical environment with strong vision, 401(k) eligibility, lodging, DEA, and leadership, infrastructure. CHA has a fully integrated electronic medical Hike, fish, ski, golf, boat or simply relax record system (Epic) throughout our inpatient units and outpatient clinics. and take in the beauty and serenity of disability coverage, state licensure. We offer a competitive, guaranteed base salary and comprehensive benefits the Adirondack Mountains CME, and med-mal. package. Please visit www.CHAproviders.org to learn more and apply through our Contact: Joanne Johnson secure candidate portal. CVs may be sent directly to Lauren Anastasia, Manager, 518-897-2706 CHA Provider Recruitment via email at [email protected]. CHA’s Department of Provider Recruitment may be reached by phone at (617) 665- [email protected] www.adirondackhealth.org 3555 or by fax at (617) 665-3553. Learn More We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual Email: [email protected] orientation, gender identity, national origin, disability status, protected veteran www.HNIhealthcare.com status, or any other characteristic protected by law. the-hospitalist.org | 29 | June 2019 Make your next smart move. Visit shmcareercenter.org.

Hospitalist & Nocturnist Opportunities in SW Virginia & NE Tennessee

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

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

Please Contact: Ballad Health Physician Recruitment 800-844-2260 [email protected]

Sweet Hospitalist Opportunity with Hospitalist Opportunity Available Penn State Health Join the Healthcare Team at Berkshire Health Systems! Penn State Health is a multi-hospital health system serving patients across central Pennsylvania seeking exceptional physicians to join our Penn State Health family to provide patient care as a Hospitalist. Berkshire Health Systems is currently seeking What we’re offering: BC/BE Internal Medicine physicians to join our • Faculty positions as well as non-teaching hospitalist positions within our multi-hospital system as well as our outpatient comprehensive Hospitalist Department practices; • Day, Evening and Nocturnist positions • Network with experienced hospitalist colleagues and • Previous Hospitalist experience is preferred collaborative leadership; Located in Western Massachusetts Berkshire • Ability to develop quality improvement projects in transition Medical Center is the region’s leading provider of of care and other scholarly pursuits of interest; comprehensive health care services • Commitment to patient safety in a team approach model; • 302-bed community teaching hospital with • Potential for growth into leadership roles; residency programs • Competitive salary, comprehensive benefit package, • A major teaching affiliate of the University of relocation, and so much more! Massachusetts Medical School and UNECOM What we’re seeking: • Geographic rounding model • Collaborative individual to work with diverse population • A closed ICU/CCU and staff; • A full spectrum of Specialties to support the team • Medical degree - MD, DO, or foreign equivalent; • 7 on/7 off 10 hour shift schedule • Completion of an accredited Internal Medicine or We understand the importance of balancing work with a Family Medicine program; healthy personal lifestyle • BC/BE in Internal or Family Medicine; • Located just 2½ hours from Boston and New York City • Must have or be able to acquire a license to practice in the Commonwealth of Pennsylvania; • Small town New England charm • No J1 visa waiver sponsorships available. • Excellent public and private schools What the area offers: • World renowned music, art, theater, and museums Located in a safe family-friendly setting in central Pennsylvania, our local neighborhoods boast a reasonable cost of living whether • Year round recreational activities from skiing to kayaking, you prefer a more suburban setting or thriving city rich in theater, arts, and culture. Our communities are rich in history and offers this is an ideal family location. an abundant range of outdoor activities, arts, and diverse experiences. We’re conveniently located within a short distance to major Berkshire Health Systems offers a competitive salary and benefits cities such as Philadelphia, Pittsburgh, NYC, Baltimore, and Washington DC. package, including relocation. For more information please contact: Heather Peffley, Physician Recruiter at: [email protected] Interested candidates are invited to contact: Liz Mahan, Physician Recruitment Specialist, Berkshire Health Systems Penn State Health is committed to affirmative action, equal opportunity and the diversity of its workforce. 725 North St. • Pittsfield, MA 01201 • (413) 395-7866. Equal Opportunity Employer – Minorities/Women/Protected Veterans/Disabled. Applications accepted online at www.berkshirehealthsystems.org

June 2019 | 30 | The Hospitalist Hospitalist Insights A warning song to keep our children safe Pay heed to “The House of the Rising Sun”

By Jordan Messler, MD, SFHM the Appalachian South. He put these songs into Dr. Messler is a hospitalist a songbook and spread them throughout the at Morton Plant Hospitalist country. He would also return to New York City group in Clearwater, Fla. “There is a house in New Orleans. They call and gather in a room with legendary folk singers. He previously chaired the Rising Sun. And it’s been the ruin of many They would hear these new lyrics, new sounds, SHM’s Quality and Patient a poor boy. And, God, I know I’m one.” and make them their own. Safety Committee and has In that room would be Lead Belly, Pete Seeger, been active in several SHM he 1960s rock band the Animals will tell Woody Guthrie, and Josh White, the fathers of folk mentoring programs, most you a tale to convince you to get vaccinat- music. The music Lomax pulled out of the moun- recently with Project BOOST ed. Don’t believe me? Follow along. tains in small towns would become new again in and Glycemic Control. The first hints of the song “House of the the guitars and harmonicas of the Greenwich Vil- TRising Sun” rolled out of the hills of Appalachia. lage singers and musicians. Pete Seeger performed Somewhere in the Golden Triangle, far away from with the Weavers, named because they would with me, including the following: New Orleans, where Virginia, Kentucky, and Tennes- weave songs from the past into new versions. • It traces the origins of folk music and the im- see rise in quiet desolation, a warning song about “House of the Rising Sun” was woven into the portance of people like Lomax and Guthrie to a tailor and a drunk emerged. Sometime around folk music landscape, evolving and growing. Josh collect and save Americana. the Civil War, a hint of a tune began. Over the next White is credited with changing the song from • The magic of musical evolution – a reminder of century, it evolved, until it became cemented in rock a major key into the minor key we know today. how art is built on the work of those who came culture 50 years ago by The Animals, existing as the Bob Dylan sang a version. And then in 1964, Eric before, each version with its unique personality. version played most commonly today. Burdon and The Animals released their version, • The release of “House of the Rising Sun” was In the mid-19th century, medicine shows rambled which became the standard. An arpeggio guitar a seminal, transformative moment when folk through the South, stopping in places like Noetown became rock music. or Daisy. The small towns would empty out for the The CDC admits they have not been • The lasting power of warning songs. day to see the entertainers, singers, and jugglers • The hucksters that enabled this song to be perform. Hundreds gathered in the hot summer targeting misinformation well. How kept alive. day, the entertainment solely a pretext for the trav- can we spread the science, the truth, That last one has really stuck with me. The eling doctors to sell their wares, the snake oil, and medicine shows are an important part of Amer- cure-alls, as well as various patent medicines. the message faster than the lies? ican history. For instance, Coca-Cola started as These were isolated towns, with no deliveries, Better marketing? The answer may one of those patent medicines; it was one of the few visitors, and the railroad yet to arrive. Fre- be through stories and narratives many concoctions of the Atlanta pharmacist quently, the only news from outside came from John Stith Pemberton, sold to treat all that ails these caravans of entertainers and con men who and song, with the backing of good us. Dr. Pepper, too, was a medicine in a sugary swept into town. They were like Professor Marvel science. bottle – another that often contained alcohol or from The Wizard of Oz, or a current-day Dr. Oz, cocaine. Society wants a cure-all, and the mar- luring the crowd with false advertising, selling keting and selling done during these medicine colored water, and then disappearing before you opening, the rhythm sped up, a louder sound, and shows offered placebos. realized you were duped. Today, traveling doctors that minor key provides an emotional wallop for The hucksters exist in various forms today, of the same ilk convince parents to not vaccinate this warning song. selling detoxifications, magic diet cures, psychic their children, tell them to visit stem cell centers Numerous covers followed, including a beauti- powers of healing, or convincing parents that that claim false cures, and offer them a shiny ob- ful version of “Amazing Grace”, sung to the tune their kids don’t need vaccines. We need a warn- ject with one hand while taking their cash with of “House of the Rising Sun” by the Blind Boys of ing song that goes viral to keep our children safe. the other. Alabama. We are blessed to be in a world without small- Yet, there was a positive development in the The song endures for its melody as well as for pox, almost rid of polio, and we have the knowl- wake of these patent medicine shows: The enter- its lyrics. This was a warning song, a universal edge and opportunity to rid the world of other tainment lingered. New songs traveled the same song, “not to do what I have done.” The small preventable illnesses. Measles was declared journeys as these medicine shows – new ear- towns in Kentucky may have heard of the sinful eliminated in the United States in 2000; now, out- worms that would then be warbled in the local ways of New Orleans and would spread the mes- breaks emerge in every news cycle. bars, while doing chores around the barn, or sim- sage with these songs to avoid the brothels, the The CDC admits they have not been targeting ply during walks on the Appalachian trails. drink, and the broken marriages that would re- misinformation well. How can we spread the sci- In 1937, Alan Lomax arrived in Noetown, Ky., verberate with visits to the Crescent City. ence, the truth, the message faster than the lies? with a microphone and an acetate record and “House of the Rising Sun” is one of the most Better marketing? The answer may be through recorded the voice of 16-year-old Georgia Turn- covered songs, traveling wide and far, no longer stories and narratives and song, with the back- er singing “House of the Rising Sun.” She didn’t with the need for a medicine show. It was a pivot- ing of good science. “House of the Rising Sun” is know where she heard that song, but most likely al moment in rock ‘n roll, turning folk music into a warning song. Maybe we need more. We need picked it up at the medicine show. rock music. The Animals became huge because that deep history, that long trail to remind us of One of those singers was Clarence Ashley, who of this song, and their version became the stan- the world before vaccines, when everyone knew would croon about the Rising Sun Blues. He sang dard on which all subsequent covers based their someone, either in their own household or next with Doc Cloud and Doc Hauer, who offered version. It made Bob Dylan’s older version seem door, who succumbed to one of the childhood tonics for whatever ailed you. Perhaps Georgia quaint. illnesses. Turner heard the song in the early 1900s as well. The song has been in my head for a while now. Let the “House of the Rising Sun” play on. Cre- Her 1937 version contains the lyrics most closely My wife is hoping writing about it will keep it ate a new version, and let that message reverber- related to the Animals’ tune. from being played in our household any more. ate, too. Lomax spent the 1940s gathering songs around There are various reasons it has been resonating Tell your children; they need to be vaccinated. the-hospitalist.org | 31 | June 2019 Extensive Recovery. Intensive Caring. When patients are discharged from a traditional hospital they sometimes need continued acute-level care.

Kindred Hospitals offer the extended recovery time and acute level of care these chronically, critically ill patients need to reach their potential.

With daily physician oversight, ICU/CCU level staffing and specially trained interdisciplinary teams, we work to improve outcomes, reduce costly readmissions and help patients transition to a lower level of care.

To learn more about Kindred Hospitals and the success of our patients, visit us at kindredhospitals.com.

Dedicated to Hope, Daily Physician Oversight • ICU/CCU-Level Staffing • Reduced Readmissions Healing and Recovery

© 2019 Kindred Healthcare, LLC CSR 197265-01, EOE

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