In a Venn diagram, patient handoffs would fall at the intersection of quality improvement (QI), patient safety, and technology.

Vineet Arora, MD, MPP, FACP, FHM, associate professor of medicine at the University of Chicago, wants hospitalists to understand that best practices in transitional care only work efficiently if they incorporate pieces from all three spheres. Hospitalists who focus too much on the outcome of an individual case might fail to utilize technology that could create a systemic protocol that would improve outcomes across multiple cases, she says. Similarly, hospitalists who leave notes in an electronic health record (EHR) can mistakenly believe that the next physician will interpret that information perfectly despite a lack of verbal and physical cues that guide verbal communication.

Dr. Arora

“People may fall into the fallacy that electronic health records actually equal good handoffs,” says Dr. Arora, a faculty member at HM12 last month in San Diego who led a breakout session that focused on the obstacles of handoffs. “The challenge is that handoffs actually are about a verbal exchange of informationa conversation and a dialogue, in conjunction with and supplemented with written communication. Technology certainly has the ability to revolutionize the way we review information and access information, but it will not change the way we speak about the information.”

The crossroads of patient safety, QI, and the use of technology from medical devices to iPhones was a major theme at SHM’s annual meeting, April 1-4 at the San Diego Convention Center. Hospitalist leaders agree that clinicians must focus on all three tenets to improve healthcare delivery, particularly in the face of generational healthcare reform. But they also acknowledge that finding a balance between best practices, budget and staffing constraints, and the rigors of daily practice is difficult.

Hospitalist Mark Lyons, MD, who works on residency programs and a patient-handoff initiative at Methodist Health System of Dallas, says that sessions on QI and patient safety provide new ideas from industry leaders who are in the trenches. To wit, he was impressed by the suggestions from Dr. Arora’s handoffs session as she described cases in which she was involved.

“They understand the limitations and the other things that go along with doing the actual act itself,” Dr. Lyons says. “They understand those things and take them into consideration. And you appreciate that.”

He and other hospitalists at HM12 agree that when leading practices are promoted at national forums, they take on the imprimatur of evidence-based procedures that physicians want to bring back to their respective HM groups. And QI suggestions promoted by physicians, not management, often tend to be more readily accepted.

“When you force change upon people, then it really leads to resistance,” Dr. Lyons says. “These are good opportunities to learn different strategies, to learn easier ways to present new ideas to people, to encourage them to do better, and to make it easier for them to do those things.”

Anuj Dalal, MD, FHM, a hospitalist at Brigham and Women’s Hospital in Boston, says technology can range from global EHRs across a multiple-institutional health system to microblogs to practice-centered wikis that promote communication between physicians. But integrating those technologies into care delivery that improves outcomes hinges not on technical hurdles, but on physicians accepting their validity and utility, he says. Once clinicians start digitally codifying the informal communication tools they currently use, patient-specific communication can improve.

And while Dr. Dalal, who co-led a session on the use of wikis as a communication-management strategy, adds that despite the little research linking those technological tacks to patient outcomes, he believes they are related.

“We’re using our devices, our iPads, our iPhones, our Android devices, to send information to other providers, but that information may not be transparent to other people,” says Dr. Dalal, who heads an SHM technology subcommittee. “But if you have it on a blog, a patient-specific Facebook, or a patient-specific Twitter, than everyone who subscribes to that will have access to the whole discussion.”

Dr. Dalal cautions that the details of legal compliance are important to ensure private patient information is safely transmitted. He anticipates vendors will market products that will balance the need for that privacy with a wider dissemination of information to ensure all involved physicians know what they need to know. One example: He expects the internal-messaging components of EHRs to improve in the next few years.

“It wouldn’t surprise me if these companies start realizing we need to support patient-specific communication in informal dialogues using microblogs and mobile devices,” he adds. “If they don’t do that, they’re probably going to miss the boat.”

The power of technology, large and small, must be balanced with what hospitalist pioneer Robert Wachter, MD, MHM, calls “foundational knowledge.” Dr. Wachter, who counts chair-elect of the American Board of Internal Medicine (ABIM) among his myriad titles, says that hospitalists can’t be slaves to technology. He relates it to a well-known adage in the aviation industry in which planes have become so advanced that some pilots would be incapable of flying them should the technology fail. In one quip, it is said that two people will soon populate cockpits: a pilot and a dog. The pilot’s job is to feed the dog, while the dog’s job is to bite the pilot’s hand if he tries to touch the controls.

Dr. Wachter

“As we move quickly, briskly, appropriately into this new world of computerization, if we aren’t constantly asking ourselves what have we lost in terms of our relationship with patients, we will really screw things up,” Dr. Wachter says. “This is not an argument to be Luddites, it’s not an argument to send back your meaningful use and get rid of the computers. We need them, but we have to be very thoughtful about how we maintain this balance.”

Patrick Conway, MD, MSc, FAAP, SFHM, a pediatric hospitalist and chief medical officer of the Centers for Medicare & Medicaid Services (CMS), says that to tie quality, safety, and technology together, government has to be willing to back therapies, then determine whether their efficacy deserves financial coverage.

One example Dr. Conway cites is the use of intravascular shunts. After backing their use initially for Medicare patients, it was determined that compared with medical management, the therapy had greater risks for death and stroke—and cost about 100 times more. Still, Dr. Conway says, determining how well the shunt works is exactly the process medicine should go through.

“When we have these new technologies that made a promise, we want to get them to market where they might help patients, but we also want to make sure evidence is developed to make sure they truly benefit patients,” he says, later adding, “I think this catalyst for health system transformation is important, and it’s teaching vision coupled with that execution.”

A well-planned blending of quality and technology can lead to improved patient safety, Dr. Arora says. But physicians and HM group leaders have to be proactive. Those with a clinical focus must seek out their IT counterparts and provide guidance on what information users need to access from electronic interfaces. Chief medical information officers and their staffs must seek feedback from providers before creating templates that don’t serve the clinical functions of end users.

Put simply: The fight to improve outcomes requires all parties to be properly armed. “You can choose a weapon,” she adds, “but you still have to choose it wisely and customize it to fit the needs of your organization.”

In a Venn diagram, patient handoffs would fall at the intersection of quality improvement (QI), patient safety, and technology.

Vineet Arora, MD, MPP, FACP, FHM, associate professor of medicine at the University of Chicago, wants hospitalists to understand that best practices in transitional care only work efficiently if they incorporate pieces from all three spheres. Hospitalists who focus too much on the outcome of an individual case might fail to utilize technology that could create a systemic protocol that would improve outcomes across multiple cases, she says. Similarly, hospitalists who leave notes in an electronic health record (EHR) can mistakenly believe that the next physician will interpret that information perfectly despite a lack of verbal and physical cues that guide verbal communication.

Dr. Arora

“People may fall into the fallacy that electronic health records actually equal good handoffs,” says Dr. Arora, a faculty member at HM12 last month in San Diego who led a breakout session that focused on the obstacles of handoffs. “The challenge is that handoffs actually are about a verbal exchange of informationa conversation and a dialogue, in conjunction with and supplemented with written communication. Technology certainly has the ability to revolutionize the way we review information and access information, but it will not change the way we speak about the information.”

The crossroads of patient safety, QI, and the use of technology from medical devices to iPhones was a major theme at SHM’s annual meeting, April 1-4 at the San Diego Convention Center. Hospitalist leaders agree that clinicians must focus on all three tenets to improve healthcare delivery, particularly in the face of generational healthcare reform. But they also acknowledge that finding a balance between best practices, budget and staffing constraints, and the rigors of daily practice is difficult.

Hospitalist Mark Lyons, MD, who works on residency programs and a patient-handoff initiative at Methodist Health System of Dallas, says that sessions on QI and patient safety provide new ideas from industry leaders who are in the trenches. To wit, he was impressed by the suggestions from Dr. Arora’s handoffs session as she described cases in which she was involved.

“They understand the limitations and the other things that go along with doing the actual act itself,” Dr. Lyons says. “They understand those things and take them into consideration. And you appreciate that.”

He and other hospitalists at HM12 agree that when leading practices are promoted at national forums, they take on the imprimatur of evidence-based procedures that physicians want to bring back to their respective HM groups. And QI suggestions promoted by physicians, not management, often tend to be more readily accepted.

“When you force change upon people, then it really leads to resistance,” Dr. Lyons says. “These are good opportunities to learn different strategies, to learn easier ways to present new ideas to people, to encourage them to do better, and to make it easier for them to do those things.”

Anuj Dalal, MD, FHM, a hospitalist at Brigham and Women’s Hospital in Boston, says technology can range from global EHRs across a multiple-institutional health system to microblogs to practice-centered wikis that promote communication between physicians. But integrating those technologies into care delivery that improves outcomes hinges not on technical hurdles, but on physicians accepting their validity and utility, he says. Once clinicians start digitally codifying the informal communication tools they currently use, patient-specific communication can improve.

And while Dr. Dalal, who co-led a session on the use of wikis as a communication-management strategy, adds that despite the little research linking those technological tacks to patient outcomes, he believes they are related.

“We’re using our devices, our iPads, our iPhones, our Android devices, to send information to other providers, but that information may not be transparent to other people,” says Dr. Dalal, who heads an SHM technology subcommittee. “But if you have it on a blog, a patient-specific Facebook, or a patient-specific Twitter, than everyone who subscribes to that will have access to the whole discussion.”

Dr. Dalal cautions that the details of legal compliance are important to ensure private patient information is safely transmitted. He anticipates vendors will market products that will balance the need for that privacy with a wider dissemination of information to ensure all involved physicians know what they need to know. One example: He expects the internal-messaging components of EHRs to improve in the next few years.

“It wouldn’t surprise me if these companies start realizing we need to support patient-specific communication in informal dialogues using microblogs and mobile devices,” he adds. “If they don’t do that, they’re probably going to miss the boat.”

The power of technology, large and small, must be balanced with what hospitalist pioneer Robert Wachter, MD, MHM, calls “foundational knowledge.” Dr. Wachter, who counts chair-elect of the American Board of Internal Medicine (ABIM) among his myriad titles, says that hospitalists can’t be slaves to technology. He relates it to a well-known adage in the aviation industry in which planes have become so advanced that some pilots would be incapable of flying them should the technology fail. In one quip, it is said that two people will soon populate cockpits: a pilot and a dog. The pilot’s job is to feed the dog, while the dog’s job is to bite the pilot’s hand if he tries to touch the controls.

Dr. Wachter

“As we move quickly, briskly, appropriately into this new world of computerization, if we aren’t constantly asking ourselves what have we lost in terms of our relationship with patients, we will really screw things up,” Dr. Wachter says. “This is not an argument to be Luddites, it’s not an argument to send back your meaningful use and get rid of the computers. We need them, but we have to be very thoughtful about how we maintain this balance.”

Patrick Conway, MD, MSc, FAAP, SFHM, a pediatric hospitalist and chief medical officer of the Centers for Medicare & Medicaid Services (CMS), says that to tie quality, safety, and technology together, government has to be willing to back therapies, then determine whether their efficacy deserves financial coverage.

One example Dr. Conway cites is the use of intravascular shunts. After backing their use initially for Medicare patients, it was determined that compared with medical management, the therapy had greater risks for death and stroke—and cost about 100 times more. Still, Dr. Conway says, determining how well the shunt works is exactly the process medicine should go through.

“When we have these new technologies that made a promise, we want to get them to market where they might help patients, but we also want to make sure evidence is developed to make sure they truly benefit patients,” he says, later adding, “I think this catalyst for health system transformation is important, and it’s teaching vision coupled with that execution.”

A well-planned blending of quality and technology can lead to improved patient safety, Dr. Arora says. But physicians and HM group leaders have to be proactive. Those with a clinical focus must seek out their IT counterparts and provide guidance on what information users need to access from electronic interfaces. Chief medical information officers and their staffs must seek feedback from providers before creating templates that don’t serve the clinical functions of end users.

Put simply: The fight to improve outcomes requires all parties to be properly armed. “You can choose a weapon,” she adds, “but you still have to choose it wisely and customize it to fit the needs of your organization.”

In a Venn diagram, patient handoffs would fall at the intersection of quality improvement (QI), patient safety, and technology.

Vineet Arora, MD, MPP, FACP, FHM, associate professor of medicine at the University of Chicago, wants hospitalists to understand that best practices in transitional care only work efficiently if they incorporate pieces from all three spheres. Hospitalists who focus too much on the outcome of an individual case might fail to utilize technology that could create a systemic protocol that would improve outcomes across multiple cases, she says. Similarly, hospitalists who leave notes in an electronic health record (EHR) can mistakenly believe that the next physician will interpret that information perfectly despite a lack of verbal and physical cues that guide verbal communication.

Dr. Arora

“People may fall into the fallacy that electronic health records actually equal good handoffs,” says Dr. Arora, a faculty member at HM12 last month in San Diego who led a breakout session that focused on the obstacles of handoffs. “The challenge is that handoffs actually are about a verbal exchange of informationa conversation and a dialogue, in conjunction with and supplemented with written communication. Technology certainly has the ability to revolutionize the way we review information and access information, but it will not change the way we speak about the information.”

The crossroads of patient safety, QI, and the use of technology from medical devices to iPhones was a major theme at SHM’s annual meeting, April 1-4 at the San Diego Convention Center. Hospitalist leaders agree that clinicians must focus on all three tenets to improve healthcare delivery, particularly in the face of generational healthcare reform. But they also acknowledge that finding a balance between best practices, budget and staffing constraints, and the rigors of daily practice is difficult.

Hospitalist Mark Lyons, MD, who works on residency programs and a patient-handoff initiative at Methodist Health System of Dallas, says that sessions on QI and patient safety provide new ideas from industry leaders who are in the trenches. To wit, he was impressed by the suggestions from Dr. Arora’s handoffs session as she described cases in which she was involved.

“They understand the limitations and the other things that go along with doing the actual act itself,” Dr. Lyons says. “They understand those things and take them into consideration. And you appreciate that.”

He and other hospitalists at HM12 agree that when leading practices are promoted at national forums, they take on the imprimatur of evidence-based procedures that physicians want to bring back to their respective HM groups. And QI suggestions promoted by physicians, not management, often tend to be more readily accepted.

“When you force change upon people, then it really leads to resistance,” Dr. Lyons says. “These are good opportunities to learn different strategies, to learn easier ways to present new ideas to people, to encourage them to do better, and to make it easier for them to do those things.”

Anuj Dalal, MD, FHM, a hospitalist at Brigham and Women’s Hospital in Boston, says technology can range from global EHRs across a multiple-institutional health system to microblogs to practice-centered wikis that promote communication between physicians. But integrating those technologies into care delivery that improves outcomes hinges not on technical hurdles, but on physicians accepting their validity and utility, he says. Once clinicians start digitally codifying the informal communication tools they currently use, patient-specific communication can improve.

And while Dr. Dalal, who co-led a session on the use of wikis as a communication-management strategy, adds that despite the little research linking those technological tacks to patient outcomes, he believes they are related.

“We’re using our devices, our iPads, our iPhones, our Android devices, to send information to other providers, but that information may not be transparent to other people,” says Dr. Dalal, who heads an SHM technology subcommittee. “But if you have it on a blog, a patient-specific Facebook, or a patient-specific Twitter, than everyone who subscribes to that will have access to the whole discussion.”

Dr. Dalal cautions that the details of legal compliance are important to ensure private patient information is safely transmitted. He anticipates vendors will market products that will balance the need for that privacy with a wider dissemination of information to ensure all involved physicians know what they need to know. One example: He expects the internal-messaging components of EHRs to improve in the next few years.

“It wouldn’t surprise me if these companies start realizing we need to support patient-specific communication in informal dialogues using microblogs and mobile devices,” he adds. “If they don’t do that, they’re probably going to miss the boat.”

The power of technology, large and small, must be balanced with what hospitalist pioneer Robert Wachter, MD, MHM, calls “foundational knowledge.” Dr. Wachter, who counts chair-elect of the American Board of Internal Medicine (ABIM) among his myriad titles, says that hospitalists can’t be slaves to technology. He relates it to a well-known adage in the aviation industry in which planes have become so advanced that some pilots would be incapable of flying them should the technology fail. In one quip, it is said that two people will soon populate cockpits: a pilot and a dog. The pilot’s job is to feed the dog, while the dog’s job is to bite the pilot’s hand if he tries to touch the controls.

Dr. Wachter

“As we move quickly, briskly, appropriately into this new world of computerization, if we aren’t constantly asking ourselves what have we lost in terms of our relationship with patients, we will really screw things up,” Dr. Wachter says. “This is not an argument to be Luddites, it’s not an argument to send back your meaningful use and get rid of the computers. We need them, but we have to be very thoughtful about how we maintain this balance.”

Patrick Conway, MD, MSc, FAAP, SFHM, a pediatric hospitalist and chief medical officer of the Centers for Medicare & Medicaid Services (CMS), says that to tie quality, safety, and technology together, government has to be willing to back therapies, then determine whether their efficacy deserves financial coverage.

One example Dr. Conway cites is the use of intravascular shunts. After backing their use initially for Medicare patients, it was determined that compared with medical management, the therapy had greater risks for death and stroke—and cost about 100 times more. Still, Dr. Conway says, determining how well the shunt works is exactly the process medicine should go through.

“When we have these new technologies that made a promise, we want to get them to market where they might help patients, but we also want to make sure evidence is developed to make sure they truly benefit patients,” he says, later adding, “I think this catalyst for health system transformation is important, and it’s teaching vision coupled with that execution.”

A well-planned blending of quality and technology can lead to improved patient safety, Dr. Arora says. But physicians and HM group leaders have to be proactive. Those with a clinical focus must seek out their IT counterparts and provide guidance on what information users need to access from electronic interfaces. Chief medical information officers and their staffs must seek feedback from providers before creating templates that don’t serve the clinical functions of end users.

Put simply: The fight to improve outcomes requires all parties to be properly armed. “You can choose a weapon,” she adds, “but you still have to choose it wisely and customize it to fit the needs of your organization.”

Jin Park, MD, is worried. She worries about the health of her patients, her hospital, and her HM group. She frets that the U.S. healthcare system will be too slow to implement must-needed change—the kind of national transformation that will improve care, contain costs, and eliminate political jousting.

“I’m a doctor with more than a decade of experience; I don’t have a personal concern. I have a community concern, a societal concern,” says Dr. Park, one of 17 hospitalists at Adventist Health in Portland, Ore. “I think adversity is good, and given the magnetism of the change, I feel like only the monsters are going to be able to survive. But you can’t just have the Kaiser [Permanentes] and the Monarch [Healthcares] and all these other examples take over the entire country. I mean, that’s not going to happen, right?”

Dr. Park wasn’t the only anxious hospitalist at HM12, held last month at the San Diego Convention Center. She and more than 150 others listened to SHM Public Policy Committee Chair Ron Greeno, MD, MHM, explain in detail the Accountable Care Organization (ACO) program being ramped up by the Centers for Medicare & Medicaid Services (CMS). Dr. Greeno, chief medical officer for Brentwood, Tenn.-based Cogent HMG, outlined how ACOs are designed to change the healthcare payment paradigm.

“They want to change doctors, hospitals, nursing homes, everybody that provides healthcare, from being profit centers to being cost centers,” Dr. Greeno said. “Right now, we’re profit centers. We do something, we get paid; we don’t do it, we don’t get paid. You see a patient, you get paid for that; your hospital admits a patient, you get paid for that. They’re a profit center. Under a [capitation] methodology, everything’s flipped on its head. If we admit a patient, we have to pay for that. We use those dollars; we’re now a cost center.”

For hospitalists, he added, that means making themselves more valuable by providing cost-effective care that translates into a healthier population.

On the Horizon: Systematic Change

While payment reform was a central theme of the annual meeting, another main takeaway was the shift of Medicare from a payor for quantity (fee-for-service) to a payor for quality (value-based purchasing).

It’s “systematically linking quality to payment,” said Patrick Conway, MD, MSc, FAAP, SFHM, a pediatric hospitalist, chief medical officer of CMS, and director of the Office of Clinical Standards and Quality at the U.S. Department of Health and Human Services in Washington, D.C. “We are transitioning to a more value-based purchaser, an active purchaser, and a catalyst for health system change. Our aims: better care for individuals, better health for populations, and lower cost for improvement.”

One in 3 Americans uses Medicare or Medicaid, the nation’s largest provider of healthcare coverage. And that number could rise when health exchanges launch in 2014 as part of the Affordable Care Act (ACA), Dr. Conway said. Combined, the two agencies spend about $800 billion annually. Medicare alone spends more than $1.5 billion per day.

Dr. Conway acknowledged the difficulty in changing the system, especially at the “ground level.” In addition to outlining key CMS’ initiatives, he indicated one of the main goals of his position is to “learn how to scale and spread successful interventions.”

They want to change doctors, hospitals, nursing homes, everybody that provides healthcare, from being profit centers to being cost centers.

—Ron Greeno, MD, MHM

“Quality can be measured and improved at multiple levels,” he told more than 2,000 hospitalists at the opening keynote address. “We’ve got the individual physician level, the group level, and then the community level. So we’re thinking about these three levels of measurement and how we align across those three levels.”

Dr. Conway, who volunteers for pediatric HM shifts on weekends, said CMS is especially excited about the Center for Medicare and Medicaid Innovation, an ACA creation that is gaining momentum with its Petri-dish-like efforts to improve quality and contain costs.

“We haven’t scaled any of these yet. We’re in testing mode,” Dr. Conway said. “I think the important point is that we have to figure out pre-testing mode, agree on evaluation models, without actuaries, that if these things work, we’re actually able to scale them to the program. This has so much robust support and applications, one could argue that we’re going to have so much interest that, one, it will be difficult to evaluate, but also, depending on how much interest you have, it could almost be at scale out of the gate.”

The Perfect Storm

National elections, Supreme Court activism, and public outrage at an “utterly dysfunctional” Congress: That’s how Norm Ornstein, PhD, MA, resident scholar at the American Enterprise Institute for Public Policy Research and a policy analyst for CBS News, views the day-to-day workings inside the Beltway.

Ornstein explained that “tribalism” is worse now than during any of his 40-plus years in Washington. He doesn’t see it getting any better, either, and wouldn’t be surprised if another wave of voter dissent tips the scales of power this November.

“We are a fairly evenly divided country,” Ornstein said, using a football analogy to describe the major political parties. “The basic reality is the Democratic Party has gravitated over to its own 20- or 25-yard line from its normal place, which was around its 40-yard line. The Republican Party, however, has moved behind its goalpost right now.”

Ornstein said he doesn’t think the U.S. Supreme Court will declare the ACA unconstitutional. Even though he’s skeptical of the conservative-leaning court’s motives, he said, “overturning even the individual mandate doesn’t make a lot of sense.”

Even so, he told hospitalists that the ever-increasing cost of healthcare, combined with America’s aging population, translates into a hostile political climate.

“All of that makes your challenge that much greater,” he said.

No matter what happens in the 2012 elections, Ornstein explained that at the end of December, a political “perfect storm” is brewing.

“Barack Obama will still be the president until Jan. 20, 2013. All of the Bush tax cuts expire the last day of December. The agreement that extended the payroll tax cut, unemployment insurance, and the doc-pay fix also expire at the end of December,” he explained. “Jan. 1, 2013, the Draconian sequesters—mindless, across-the-board cuts in defense and discretionary spending, not sparing any programs, designed to try and force them to the table to reach a broader budget deal but they couldn’t reach—all begin. And that’s $50 billion taken from what is already a pretty tight discretionary domestic budget.

“So fasten your seat belts for what’s going to be an extremely bumpy ride over the next several months, and a very murky picture for what will follow.”

Don’t Give Up

Many hospitalists think advocacy is beyond their pay grade, assuming their voice or idea will get lost in the bureaucracy that is the nation’s capital. Dr. Conway exhorted hospitalists to stay in the fight, partner with hospital administration, and champion quality initiatives.

“We’re all in this together,” he said. “You can understand your hospital’s performance statement, share data within and outside your hospital, be actively engaged in your hospital value-based purchasing programs and inpatient quality reporting. Physician leadership and professionalism, I think, is incredibly important.”

Jin Park, MD, is worried. She worries about the health of her patients, her hospital, and her HM group. She frets that the U.S. healthcare system will be too slow to implement must-needed change—the kind of national transformation that will improve care, contain costs, and eliminate political jousting.

“I’m a doctor with more than a decade of experience; I don’t have a personal concern. I have a community concern, a societal concern,” says Dr. Park, one of 17 hospitalists at Adventist Health in Portland, Ore. “I think adversity is good, and given the magnetism of the change, I feel like only the monsters are going to be able to survive. But you can’t just have the Kaiser [Permanentes] and the Monarch [Healthcares] and all these other examples take over the entire country. I mean, that’s not going to happen, right?”

Dr. Park wasn’t the only anxious hospitalist at HM12, held last month at the San Diego Convention Center. She and more than 150 others listened to SHM Public Policy Committee Chair Ron Greeno, MD, MHM, explain in detail the Accountable Care Organization (ACO) program being ramped up by the Centers for Medicare & Medicaid Services (CMS). Dr. Greeno, chief medical officer for Brentwood, Tenn.-based Cogent HMG, outlined how ACOs are designed to change the healthcare payment paradigm.

“They want to change doctors, hospitals, nursing homes, everybody that provides healthcare, from being profit centers to being cost centers,” Dr. Greeno said. “Right now, we’re profit centers. We do something, we get paid; we don’t do it, we don’t get paid. You see a patient, you get paid for that; your hospital admits a patient, you get paid for that. They’re a profit center. Under a [capitation] methodology, everything’s flipped on its head. If we admit a patient, we have to pay for that. We use those dollars; we’re now a cost center.”

For hospitalists, he added, that means making themselves more valuable by providing cost-effective care that translates into a healthier population.

On the Horizon: Systematic Change

While payment reform was a central theme of the annual meeting, another main takeaway was the shift of Medicare from a payor for quantity (fee-for-service) to a payor for quality (value-based purchasing).

It’s “systematically linking quality to payment,” said Patrick Conway, MD, MSc, FAAP, SFHM, a pediatric hospitalist, chief medical officer of CMS, and director of the Office of Clinical Standards and Quality at the U.S. Department of Health and Human Services in Washington, D.C. “We are transitioning to a more value-based purchaser, an active purchaser, and a catalyst for health system change. Our aims: better care for individuals, better health for populations, and lower cost for improvement.”

One in 3 Americans uses Medicare or Medicaid, the nation’s largest provider of healthcare coverage. And that number could rise when health exchanges launch in 2014 as part of the Affordable Care Act (ACA), Dr. Conway said. Combined, the two agencies spend about $800 billion annually. Medicare alone spends more than $1.5 billion per day.

Dr. Conway acknowledged the difficulty in changing the system, especially at the “ground level.” In addition to outlining key CMS’ initiatives, he indicated one of the main goals of his position is to “learn how to scale and spread successful interventions.”

They want to change doctors, hospitals, nursing homes, everybody that provides healthcare, from being profit centers to being cost centers.

—Ron Greeno, MD, MHM

“Quality can be measured and improved at multiple levels,” he told more than 2,000 hospitalists at the opening keynote address. “We’ve got the individual physician level, the group level, and then the community level. So we’re thinking about these three levels of measurement and how we align across those three levels.”

Dr. Conway, who volunteers for pediatric HM shifts on weekends, said CMS is especially excited about the Center for Medicare and Medicaid Innovation, an ACA creation that is gaining momentum with its Petri-dish-like efforts to improve quality and contain costs.

“We haven’t scaled any of these yet. We’re in testing mode,” Dr. Conway said. “I think the important point is that we have to figure out pre-testing mode, agree on evaluation models, without actuaries, that if these things work, we’re actually able to scale them to the program. This has so much robust support and applications, one could argue that we’re going to have so much interest that, one, it will be difficult to evaluate, but also, depending on how much interest you have, it could almost be at scale out of the gate.”

The Perfect Storm

National elections, Supreme Court activism, and public outrage at an “utterly dysfunctional” Congress: That’s how Norm Ornstein, PhD, MA, resident scholar at the American Enterprise Institute for Public Policy Research and a policy analyst for CBS News, views the day-to-day workings inside the Beltway.

Ornstein explained that “tribalism” is worse now than during any of his 40-plus years in Washington. He doesn’t see it getting any better, either, and wouldn’t be surprised if another wave of voter dissent tips the scales of power this November.

“We are a fairly evenly divided country,” Ornstein said, using a football analogy to describe the major political parties. “The basic reality is the Democratic Party has gravitated over to its own 20- or 25-yard line from its normal place, which was around its 40-yard line. The Republican Party, however, has moved behind its goalpost right now.”

Ornstein said he doesn’t think the U.S. Supreme Court will declare the ACA unconstitutional. Even though he’s skeptical of the conservative-leaning court’s motives, he said, “overturning even the individual mandate doesn’t make a lot of sense.”

Even so, he told hospitalists that the ever-increasing cost of healthcare, combined with America’s aging population, translates into a hostile political climate.

“All of that makes your challenge that much greater,” he said.

No matter what happens in the 2012 elections, Ornstein explained that at the end of December, a political “perfect storm” is brewing.

“Barack Obama will still be the president until Jan. 20, 2013. All of the Bush tax cuts expire the last day of December. The agreement that extended the payroll tax cut, unemployment insurance, and the doc-pay fix also expire at the end of December,” he explained. “Jan. 1, 2013, the Draconian sequesters—mindless, across-the-board cuts in defense and discretionary spending, not sparing any programs, designed to try and force them to the table to reach a broader budget deal but they couldn’t reach—all begin. And that’s $50 billion taken from what is already a pretty tight discretionary domestic budget.

“So fasten your seat belts for what’s going to be an extremely bumpy ride over the next several months, and a very murky picture for what will follow.”

Don’t Give Up

Many hospitalists think advocacy is beyond their pay grade, assuming their voice or idea will get lost in the bureaucracy that is the nation’s capital. Dr. Conway exhorted hospitalists to stay in the fight, partner with hospital administration, and champion quality initiatives.

“We’re all in this together,” he said. “You can understand your hospital’s performance statement, share data within and outside your hospital, be actively engaged in your hospital value-based purchasing programs and inpatient quality reporting. Physician leadership and professionalism, I think, is incredibly important.”

Jin Park, MD, is worried. She worries about the health of her patients, her hospital, and her HM group. She frets that the U.S. healthcare system will be too slow to implement must-needed change—the kind of national transformation that will improve care, contain costs, and eliminate political jousting.

“I’m a doctor with more than a decade of experience; I don’t have a personal concern. I have a community concern, a societal concern,” says Dr. Park, one of 17 hospitalists at Adventist Health in Portland, Ore. “I think adversity is good, and given the magnetism of the change, I feel like only the monsters are going to be able to survive. But you can’t just have the Kaiser [Permanentes] and the Monarch [Healthcares] and all these other examples take over the entire country. I mean, that’s not going to happen, right?”

Dr. Park wasn’t the only anxious hospitalist at HM12, held last month at the San Diego Convention Center. She and more than 150 others listened to SHM Public Policy Committee Chair Ron Greeno, MD, MHM, explain in detail the Accountable Care Organization (ACO) program being ramped up by the Centers for Medicare & Medicaid Services (CMS). Dr. Greeno, chief medical officer for Brentwood, Tenn.-based Cogent HMG, outlined how ACOs are designed to change the healthcare payment paradigm.

“They want to change doctors, hospitals, nursing homes, everybody that provides healthcare, from being profit centers to being cost centers,” Dr. Greeno said. “Right now, we’re profit centers. We do something, we get paid; we don’t do it, we don’t get paid. You see a patient, you get paid for that; your hospital admits a patient, you get paid for that. They’re a profit center. Under a [capitation] methodology, everything’s flipped on its head. If we admit a patient, we have to pay for that. We use those dollars; we’re now a cost center.”

For hospitalists, he added, that means making themselves more valuable by providing cost-effective care that translates into a healthier population.

On the Horizon: Systematic Change

While payment reform was a central theme of the annual meeting, another main takeaway was the shift of Medicare from a payor for quantity (fee-for-service) to a payor for quality (value-based purchasing).

It’s “systematically linking quality to payment,” said Patrick Conway, MD, MSc, FAAP, SFHM, a pediatric hospitalist, chief medical officer of CMS, and director of the Office of Clinical Standards and Quality at the U.S. Department of Health and Human Services in Washington, D.C. “We are transitioning to a more value-based purchaser, an active purchaser, and a catalyst for health system change. Our aims: better care for individuals, better health for populations, and lower cost for improvement.”

One in 3 Americans uses Medicare or Medicaid, the nation’s largest provider of healthcare coverage. And that number could rise when health exchanges launch in 2014 as part of the Affordable Care Act (ACA), Dr. Conway said. Combined, the two agencies spend about $800 billion annually. Medicare alone spends more than $1.5 billion per day.

Dr. Conway acknowledged the difficulty in changing the system, especially at the “ground level.” In addition to outlining key CMS’ initiatives, he indicated one of the main goals of his position is to “learn how to scale and spread successful interventions.”

They want to change doctors, hospitals, nursing homes, everybody that provides healthcare, from being profit centers to being cost centers.

—Ron Greeno, MD, MHM

“Quality can be measured and improved at multiple levels,” he told more than 2,000 hospitalists at the opening keynote address. “We’ve got the individual physician level, the group level, and then the community level. So we’re thinking about these three levels of measurement and how we align across those three levels.”

Dr. Conway, who volunteers for pediatric HM shifts on weekends, said CMS is especially excited about the Center for Medicare and Medicaid Innovation, an ACA creation that is gaining momentum with its Petri-dish-like efforts to improve quality and contain costs.

“We haven’t scaled any of these yet. We’re in testing mode,” Dr. Conway said. “I think the important point is that we have to figure out pre-testing mode, agree on evaluation models, without actuaries, that if these things work, we’re actually able to scale them to the program. This has so much robust support and applications, one could argue that we’re going to have so much interest that, one, it will be difficult to evaluate, but also, depending on how much interest you have, it could almost be at scale out of the gate.”

The Perfect Storm

National elections, Supreme Court activism, and public outrage at an “utterly dysfunctional” Congress: That’s how Norm Ornstein, PhD, MA, resident scholar at the American Enterprise Institute for Public Policy Research and a policy analyst for CBS News, views the day-to-day workings inside the Beltway.

Ornstein explained that “tribalism” is worse now than during any of his 40-plus years in Washington. He doesn’t see it getting any better, either, and wouldn’t be surprised if another wave of voter dissent tips the scales of power this November.

“We are a fairly evenly divided country,” Ornstein said, using a football analogy to describe the major political parties. “The basic reality is the Democratic Party has gravitated over to its own 20- or 25-yard line from its normal place, which was around its 40-yard line. The Republican Party, however, has moved behind its goalpost right now.”

Ornstein said he doesn’t think the U.S. Supreme Court will declare the ACA unconstitutional. Even though he’s skeptical of the conservative-leaning court’s motives, he said, “overturning even the individual mandate doesn’t make a lot of sense.”

Even so, he told hospitalists that the ever-increasing cost of healthcare, combined with America’s aging population, translates into a hostile political climate.

“All of that makes your challenge that much greater,” he said.

No matter what happens in the 2012 elections, Ornstein explained that at the end of December, a political “perfect storm” is brewing.

“Barack Obama will still be the president until Jan. 20, 2013. All of the Bush tax cuts expire the last day of December. The agreement that extended the payroll tax cut, unemployment insurance, and the doc-pay fix also expire at the end of December,” he explained. “Jan. 1, 2013, the Draconian sequesters—mindless, across-the-board cuts in defense and discretionary spending, not sparing any programs, designed to try and force them to the table to reach a broader budget deal but they couldn’t reach—all begin. And that’s $50 billion taken from what is already a pretty tight discretionary domestic budget.

“So fasten your seat belts for what’s going to be an extremely bumpy ride over the next several months, and a very murky picture for what will follow.”

Don’t Give Up

Many hospitalists think advocacy is beyond their pay grade, assuming their voice or idea will get lost in the bureaucracy that is the nation’s capital. Dr. Conway exhorted hospitalists to stay in the fight, partner with hospital administration, and champion quality initiatives.

“We’re all in this together,” he said. “You can understand your hospital’s performance statement, share data within and outside your hospital, be actively engaged in your hospital value-based purchasing programs and inpatient quality reporting. Physician leadership and professionalism, I think, is incredibly important.”

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Online calculator helps prevent post-op respiratory failure
2. New drug for long-term treatment of PE
3. Benefits of triple therapy for COPD
4. Knee-length compression stockings as good as thigh-length for PTS
5. Video monitoring improves hand hygiene
6. Asymptomatic bacteriuria often misdiagnosed as UTI
7. CT accurate for lower GI bleeding diagnosis
8. Switch from albuterol to lavalbuterol to reduce tachycardia not recommended

Preoperative Risk Calculator Can Help Predict Postoperative Respiratory Failure

Clinical question: Can preoperative factors identify patients at risk for postoperative respiratory failure (PRF)?

Background: PRF—when a patient requires mechanical ventilation >48 hours after surgery or needs unplanned intubation within 30 days of surgery—is associated with high mortality, with 30-day mortality rates of 26%.

Study design: Analysis of multicenter, prospective databases of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP).

Setting: Analysis of NSQIP data from 2007 (training set) and 2008 (validation set).

Synopsis: PRF was seen in 3.1% of patients in the 2007 data set and 2.6% in the 2008 data set. Those with PRF had significantly higher mortality rates than those without PRF (25.62% vs. 0.98%; P<0.0001). Preoperative risk factors associated with significantly increased risk of PRF were American Society of Anesthesiologists’ class, functional status, emergent nature of procedure, type of surgery, and preoperative sepsis.

The 2007 data set was used to develop the model, and the 2008 data set was used as a validation set. The selected risk model showed similar results in both sets with a c-statistic of 0.91 in the training set and 0.90 in the validation set. This selected model was then used to develop an interactive calculator predicting PRF (available at www.surgicalriskcalculator.com/prf-risk-calculator).

Bottom line: The PRF risk calculator can identify patients at high risk for PRF, which can aid in tailoring preventive strategies for patients prior to surgery.

Citation: Gupta H, Gupta PK, Fang X, et al. Development and validation of a risk calculator predicting postoperative respiratory failure. Chest. 2011;140:1207-1215.

New Drug for Treatment of Acute Symptomatic Pulmonary Embolism

Clinical question: Is the incidence of recurrent venous thromboembolism (VTE) or bleeding with use of idrabiotaparinux comparable to warfarin for treatment of acute symptomatic pulmonary embolism (PE)?

Background: Warfarin is an effective treatment for PE; however, maintenance of effective and safe levels of anticoagulation is difficult to achieve. A straightforward treatment option would be an attractive alternative. Idrabiotaparinux, a factor Xa inhibitor bound with a biotin moiety, is a weekly subcutaneous injection proposed as an alternative to warfarin for treatment of PE.

Study design: Industry-sponsored double-blind, randomized controlled trial.

Setting: 291 centers in 37 countries.

Synopsis: A group of 3,202 patients aged 18 to 96 years were randomly assigned to receive enoxaparin, followed by idrabiotaparinux or enoxaparin, then overlapped and followed by warfarin for three or six months. The incidence of recurrent VTE (including fatal and nonfatal PE or deep vein thrombosis) did not differ between the two treatment arms.

Of the 1,599 patients treated with idrabiotaparinux, 48 (3%) had a recurrence; of the 1,603 treated with warfarin, 97 (6%) had a recurrence (odds ratio, 0.49). The rate of clinically relevant bleeding was also similar, with 72 (5%) in the idrabiotaparinux group versus 106 (7%) in the warfarin group. Much like warfarin, idrabiotaparinux requires bridging therapy with initial low-molecular-weight heparin.

Bottom line: Use of enoxaparin followed by weekly subcutaneous injection of idrabiotaparinux was as effective as enoxaparin followed by warfarin for preventing recurrent VTE, and may provide a suitable option for treatment of acute symptomatic PE.

Citation: Buller HR, Gallus AS, Pillion G, Prins MH, Raskob GE. Enoxaparin followed by once-weekly idrabiotaparinux versus enoxaparin plus warfarin for patients with acute symptomatic pulmonary embolism: a randomised, double-blind, double-dummy, non-inferiority trial. Lancet. 2012;379:123-129.

Triple Therapy Better than Double for COPD

Clinical question: Does addition of tiotropium to inhaled corticosteroids and long-acting beta-agonists (LABA) have an additive benefit in reducing mortality, hospital admissions, and exacerbations in COPD?

Background: Triple therapy in COPD involves adding LABA and long-acting antimuscarinics (LAMA), such as tiotropium, to inhaled corticosteroids (ICS). Despite the guidelines recommending triple therapy for severe COPD, most studies have evaluated either LAMA or LABA plus ICS, but not all three together.

Study design: Retrospective cohort.

Setting: Tayside, Scotland’s National Health Services database.

Synopsis: Patients with severe COPD were divided into two groups: 1,857 patients had received ICS+LABA (double therapy) and 996 had received ICS+LABA+tiotropium (triple therapy), with follow-up of 4.65 years.

All-cause mortality was 35% lower in the triple therapy group (HR 0.65, 95% CI 0.57-0.75). Corticosteroid use was 29% lower (HR 0.71, 95% CI 0.63-0.80), and hospital admissions were 15% lower (HR 0.85, 95% CI 0.73-0.99) in the triple-therapy group. These results were adjusted for smoking, age, sex, socioeconomic status, and history of diabetes, cardiovascular, and respiratory disease.

This study is limited by its observational retrospective design but provides good evidence of the need for randomized controlled trials to validate the clinical benefits of triple therapy.

Bottom line: Adding tiotropium to ICS plus LABA is associated with lower all-cause mortality, hospitalizations, and corticosteroid use when compared with ICS plus LABA, validating its current use in management of severe COPD.

Citation: Short PM, Williamson PA, Elder DHJ, Lipworth SIW, Schembi S, Lipworth BJ. The impact of tiotropium on mortality and exacerbations when added to inhaled corticosteroids and long-acting β-agonist therapy in COPD. Chest. 2012;141:81-86.

Above-Knee Compression Stockings Not Better than Below-Knee Stockings for Protection Against Post-Thrombotic Syndrome

Clinical question: Do above-knee compression elastic stockings prevent post-thrombotic syndrome (PTS) better than below-knee stockings?

Background: PTS—characterized by leg pain, cramps, edema, and hyperpigmentation—occurs in 25% to 50% of patients after an episode of deep venous thrombosis (DVT). Previous studies demonstrated a 50% reduction in the incidence of PTS when patients used below-knee stockings.

Study design: Open-label, randomized clinical trial.

Setting: Eight hospitals in Italy.

Synopsis: A total of 267 patients with their first episode of DVT were randomized to thigh-length or below-knee compression elastic stockings, as well as therapeutic anticoagulation, with a primary endpoint of three-year incidence of PTS. Assessment was done by study personnel who were blinded to the type of stocking the patients had been prescribed. Severity of PTS was graded by a scoring system incorporating objective and subjective criteria with an independent adjudicator.

The intention-to-treat analysis showed no significant difference in the three-year incidence of PTS between thigh- and knee-length stockings (32.6% vs. 35.6%, respectively). Compliance was better in the knee-length (82.6%) than in the thigh-length (66.7%) group due to the significantly lower rate of stockings-related side effects.

The study is limited by a lack of blinding in the study participants.

Bottom line: Knee-length stockings offer equal similar protection against PTS with better compliance when compared with thigh-length stockings.

Citation: Prandoni P, Noventa F, Quintavalla R, et al. Thigh-length versus below-knee compression elastic stockings for prevention of the post-thrombotic syndrome in patients with proximal-venous thrombosis: a randomized trial. Blood. 2012;119:1561-1565.

Video Auditing With Near- Real-Time Feedback Improves Hand Hygiene Practices

Clinical question: Does the use of direct video monitoring with continuous, multi-modal feedback promote improvement in healthcare workers’ compliance with hand hygiene?

Background: Appropriate hand hygiene is an effective means of infection control. Direct human observation of hand hygiene compliance does little more than provide a biased, temporary, and often overestimated assessment of compliance. The use of video-based monitoring technology in other aspects of society (e.g. traffic signal cameras) has been well demonstrated to modify behavior.

Study design: Prospective cohort study.

Setting: Tertiary-care hospital’s 17-bed medical ICU in the northeastern U.S.

Synopsis: Through the use of 21 motion-activated video cameras with continuous third-party auditing, the provision of near real-time feedback improved hand hygiene rates of healthcare workers from 6.5% to 81.6%. In the four months preceding feedback, only 3,933 hand-washing events out of 60,542 (6.5%) were considered “passing.” During the active feedback period, 59,627 events out of 73,080 (81.6%) passed.

The improvement was sustained in the maintenance period of the study with an average rate of hand hygiene compliance of 87.9%. The improvement in hand hygiene compliance required active provision of feedback as well as the presence of monitoring equipment, making the applicability of this study limited, based on the cost of the technology and the manpower to provide feedback.

Bottom line: Hand hygiene practices improve when healthcare workers are given immediate feedback on their compliance.

Citation: Rebellion D, Husain E, Schilling ME, et al. Using high-technology to enforce low-technology safety measures: the use of third-party remote video auditing and real-time feedback in healthcare. Clin Infect Dis. 2012:54(1):1-7.

Mismanagement of Enterococcal Bacteriuria

Clinical question: Are clinical providers following appropriate guidelines to identify and manage enterococcal bacteriuria?

Background: There are specific evidence-based guidelines for the diagnosis and treatment of urinary tract infections (UTI) and asymptomatic bacteriuria (ABU). ABU is often mistaken for a UTI, and incorrectly treated as one.

Study design: Retrospective cohort.

Setting: Two academic teaching hospitals in Houston, Texas.

Synopsis: Using the current Infectious Disease Society of America (IDSA) guidelines, 375 Enterococcus urine cultures were reviewed and determined to be either UTI or ABU. The cultures were initially reviewed for appropriate treatment and again 30 days later for complications. UTI was defined as bacteriuria with one or more sign or symptom (urgency, frequency, dysuria, suprapubic tenderness, flank pain, rigors, visible hematuria, delirium, or fevers) without another identifiable cause. ABU was defined as bacteriuria without any of the signs or symptoms, or a clear nonurinary source.

Of the 339 cultures matching inclusion criteria, 156 were classified as UTI and 183 classified as ABU. Sixty of the 183 ABU (32.8%) were inappropriately treated with antibiotics, while antibiotics were withheld in 23 of the 156 UTI (14.7%). Eighty-three of 339 cultures (24.5%) were incorrectly treated. The most common reason for ABU being inappropriately treated was the presence of pyuria, associated with a threefold higher use of antibiotics.

There was no significant difference in subsequent infections or infectious complications between UTI and ABU.

Bottom line: Enterococcal ABU is frequently treated with antibiotics, even though guidelines recommend against it; providers should resist overtreating enterococcal ABU.

Citation: Lin E, Bhusal Y, Horwitz D, Shelburne SA, Trautner BW. Overtreatment of enterococcal bacteriuria. Arch Intern Med. 2012;172:33-38.

CT Angiography for the Diagnosis of Acute Lower GI Bleeding in an Emergency Setting

Clinical question: Is CT angiography a reliable initial diagnostic procedure to identify the presence and location of an acute lower gastrointestinal (GI) bleed in the ED setting?

Background: CT angiography has been identified as a potentially useful procedure to identify acute GI bleeds; however, the specific role and timing of the procedure has not been clearly identified.

Study design: Prospective study.

Setting: ED of a university-based hospital in Madrid.

Synopsis: CT angiography was performed on 47 ED patients (27 men, 20 women, with a mean age of 68 years) with an acute lower GI bleed. Study protocol included a preliminary unenhanced CT scan followed by CT angiogram prior to the standard clinical protocol, which included colonoscopy, angiography, or laparotomy.

Images were reviewed by two different ED radiologists, who were blinded to the diagnosis, and compared with the standard protocol findings. CT angiography correctly identified active acute or recent GI bleeding in 46 of the 47 patients, with a sensitivity of 100% (19 of 19), NPV of 100% (27 of 27), specificity of 96% (27 of 28), and PPV of 95% (19 of 20). CT angiography also was 93% accurate in identifying the cause of the GI bleed when compared with the standard reference.

Limitations of the study include its small size and the lack of a control group.

Bottom line: CT angiography is an accurate and more readily available modality for the diagnosis of acute lower GI bleeding, though it does not provide a therapeutic option.

Citation: Martí M, Artigas JM, Garzón G, Alvarez-Sala R, Soto JA. Acute lower intestinal bleeding: feasibility and diagnostic performance of CT angiography. Radiology. 2012;262:109-116.

Substitution of Levalbuterol to Avoid Tachyarrhythmia Not Supported

Clinical question: Does substitution of levalbuterol for albuterol in critically ill adult patients result in decreased incidence of tachyarrhythmias?

Background: Studies have indicated an increased risk of mortality from tachycardia and tachyarrhythmias in ICU patients. Levalbuterol is the R-isomer of albuterol, and it has been proposed that it may mitigate cardiac side effects seen with beta-2 agonists. For this reason, some clinicians have advocated using nebulized levalbuterol in critically ill patients.

Study design: Prospective randomized controlled trial with patient crossover.

Setting: Single academic medical center.

Synopsis: All ICU patients in a single teaching hospital were screened, and 70 patients were included. Patients were randomly crossed over between albuterol and levalbuterol every four to six hours. This resulted in a total of 836 measurements of heart rate, the primary outcome measurement. The study showed no clinically significant differences in average heart rate when using levalbuterol versus albuterol. This was a small study of ICU patients, using a surrogate endpoint of heart rate rather than mortality. Furthermore, the assessment of tachyarrhythmias was limited given the study size and relative rarity of these events. Despite these limitations, the study casts significant doubt on the theory and practice of switching from albuterol to levalbuterol solely for the purpose of reducing or avoiding tachycardia or tachyarrhythmias.

Bottom line: Substitution of levalbuterol for albuterol to avert tachycardia in critically ill patients is not warranted.

Citation: Khorfan FM, Smith P, Watt S, Barber KR. Effects of nebulized bronchodilator therapy on heart rate and arrhythmias in critically ill adult patients. Chest. 2011;140:1466-1472.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Online calculator helps prevent post-op respiratory failure
2. New drug for long-term treatment of PE
3. Benefits of triple therapy for COPD
4. Knee-length compression stockings as good as thigh-length for PTS
5. Video monitoring improves hand hygiene
6. Asymptomatic bacteriuria often misdiagnosed as UTI
7. CT accurate for lower GI bleeding diagnosis
8. Switch from albuterol to lavalbuterol to reduce tachycardia not recommended

Preoperative Risk Calculator Can Help Predict Postoperative Respiratory Failure

Clinical question: Can preoperative factors identify patients at risk for postoperative respiratory failure (PRF)?

Background: PRF—when a patient requires mechanical ventilation >48 hours after surgery or needs unplanned intubation within 30 days of surgery—is associated with high mortality, with 30-day mortality rates of 26%.

Study design: Analysis of multicenter, prospective databases of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP).

Setting: Analysis of NSQIP data from 2007 (training set) and 2008 (validation set).

Synopsis: PRF was seen in 3.1% of patients in the 2007 data set and 2.6% in the 2008 data set. Those with PRF had significantly higher mortality rates than those without PRF (25.62% vs. 0.98%; P<0.0001). Preoperative risk factors associated with significantly increased risk of PRF were American Society of Anesthesiologists’ class, functional status, emergent nature of procedure, type of surgery, and preoperative sepsis.

The 2007 data set was used to develop the model, and the 2008 data set was used as a validation set. The selected risk model showed similar results in both sets with a c-statistic of 0.91 in the training set and 0.90 in the validation set. This selected model was then used to develop an interactive calculator predicting PRF (available at www.surgicalriskcalculator.com/prf-risk-calculator).

Bottom line: The PRF risk calculator can identify patients at high risk for PRF, which can aid in tailoring preventive strategies for patients prior to surgery.

Citation: Gupta H, Gupta PK, Fang X, et al. Development and validation of a risk calculator predicting postoperative respiratory failure. Chest. 2011;140:1207-1215.

New Drug for Treatment of Acute Symptomatic Pulmonary Embolism

Clinical question: Is the incidence of recurrent venous thromboembolism (VTE) or bleeding with use of idrabiotaparinux comparable to warfarin for treatment of acute symptomatic pulmonary embolism (PE)?

Background: Warfarin is an effective treatment for PE; however, maintenance of effective and safe levels of anticoagulation is difficult to achieve. A straightforward treatment option would be an attractive alternative. Idrabiotaparinux, a factor Xa inhibitor bound with a biotin moiety, is a weekly subcutaneous injection proposed as an alternative to warfarin for treatment of PE.

Study design: Industry-sponsored double-blind, randomized controlled trial.

Setting: 291 centers in 37 countries.

Synopsis: A group of 3,202 patients aged 18 to 96 years were randomly assigned to receive enoxaparin, followed by idrabiotaparinux or enoxaparin, then overlapped and followed by warfarin for three or six months. The incidence of recurrent VTE (including fatal and nonfatal PE or deep vein thrombosis) did not differ between the two treatment arms.

Of the 1,599 patients treated with idrabiotaparinux, 48 (3%) had a recurrence; of the 1,603 treated with warfarin, 97 (6%) had a recurrence (odds ratio, 0.49). The rate of clinically relevant bleeding was also similar, with 72 (5%) in the idrabiotaparinux group versus 106 (7%) in the warfarin group. Much like warfarin, idrabiotaparinux requires bridging therapy with initial low-molecular-weight heparin.

Bottom line: Use of enoxaparin followed by weekly subcutaneous injection of idrabiotaparinux was as effective as enoxaparin followed by warfarin for preventing recurrent VTE, and may provide a suitable option for treatment of acute symptomatic PE.

Citation: Buller HR, Gallus AS, Pillion G, Prins MH, Raskob GE. Enoxaparin followed by once-weekly idrabiotaparinux versus enoxaparin plus warfarin for patients with acute symptomatic pulmonary embolism: a randomised, double-blind, double-dummy, non-inferiority trial. Lancet. 2012;379:123-129.

Triple Therapy Better than Double for COPD

Clinical question: Does addition of tiotropium to inhaled corticosteroids and long-acting beta-agonists (LABA) have an additive benefit in reducing mortality, hospital admissions, and exacerbations in COPD?

Background: Triple therapy in COPD involves adding LABA and long-acting antimuscarinics (LAMA), such as tiotropium, to inhaled corticosteroids (ICS). Despite the guidelines recommending triple therapy for severe COPD, most studies have evaluated either LAMA or LABA plus ICS, but not all three together.

Study design: Retrospective cohort.

Setting: Tayside, Scotland’s National Health Services database.

Synopsis: Patients with severe COPD were divided into two groups: 1,857 patients had received ICS+LABA (double therapy) and 996 had received ICS+LABA+tiotropium (triple therapy), with follow-up of 4.65 years.

All-cause mortality was 35% lower in the triple therapy group (HR 0.65, 95% CI 0.57-0.75). Corticosteroid use was 29% lower (HR 0.71, 95% CI 0.63-0.80), and hospital admissions were 15% lower (HR 0.85, 95% CI 0.73-0.99) in the triple-therapy group. These results were adjusted for smoking, age, sex, socioeconomic status, and history of diabetes, cardiovascular, and respiratory disease.

This study is limited by its observational retrospective design but provides good evidence of the need for randomized controlled trials to validate the clinical benefits of triple therapy.

Bottom line: Adding tiotropium to ICS plus LABA is associated with lower all-cause mortality, hospitalizations, and corticosteroid use when compared with ICS plus LABA, validating its current use in management of severe COPD.

Citation: Short PM, Williamson PA, Elder DHJ, Lipworth SIW, Schembi S, Lipworth BJ. The impact of tiotropium on mortality and exacerbations when added to inhaled corticosteroids and long-acting β-agonist therapy in COPD. Chest. 2012;141:81-86.

Above-Knee Compression Stockings Not Better than Below-Knee Stockings for Protection Against Post-Thrombotic Syndrome

Clinical question: Do above-knee compression elastic stockings prevent post-thrombotic syndrome (PTS) better than below-knee stockings?

Background: PTS—characterized by leg pain, cramps, edema, and hyperpigmentation—occurs in 25% to 50% of patients after an episode of deep venous thrombosis (DVT). Previous studies demonstrated a 50% reduction in the incidence of PTS when patients used below-knee stockings.

Study design: Open-label, randomized clinical trial.

Setting: Eight hospitals in Italy.

Synopsis: A total of 267 patients with their first episode of DVT were randomized to thigh-length or below-knee compression elastic stockings, as well as therapeutic anticoagulation, with a primary endpoint of three-year incidence of PTS. Assessment was done by study personnel who were blinded to the type of stocking the patients had been prescribed. Severity of PTS was graded by a scoring system incorporating objective and subjective criteria with an independent adjudicator.

The intention-to-treat analysis showed no significant difference in the three-year incidence of PTS between thigh- and knee-length stockings (32.6% vs. 35.6%, respectively). Compliance was better in the knee-length (82.6%) than in the thigh-length (66.7%) group due to the significantly lower rate of stockings-related side effects.

The study is limited by a lack of blinding in the study participants.

Bottom line: Knee-length stockings offer equal similar protection against PTS with better compliance when compared with thigh-length stockings.

Citation: Prandoni P, Noventa F, Quintavalla R, et al. Thigh-length versus below-knee compression elastic stockings for prevention of the post-thrombotic syndrome in patients with proximal-venous thrombosis: a randomized trial. Blood. 2012;119:1561-1565.

Video Auditing With Near- Real-Time Feedback Improves Hand Hygiene Practices

Clinical question: Does the use of direct video monitoring with continuous, multi-modal feedback promote improvement in healthcare workers’ compliance with hand hygiene?

Background: Appropriate hand hygiene is an effective means of infection control. Direct human observation of hand hygiene compliance does little more than provide a biased, temporary, and often overestimated assessment of compliance. The use of video-based monitoring technology in other aspects of society (e.g. traffic signal cameras) has been well demonstrated to modify behavior.

Study design: Prospective cohort study.

Setting: Tertiary-care hospital’s 17-bed medical ICU in the northeastern U.S.

Synopsis: Through the use of 21 motion-activated video cameras with continuous third-party auditing, the provision of near real-time feedback improved hand hygiene rates of healthcare workers from 6.5% to 81.6%. In the four months preceding feedback, only 3,933 hand-washing events out of 60,542 (6.5%) were considered “passing.” During the active feedback period, 59,627 events out of 73,080 (81.6%) passed.

The improvement was sustained in the maintenance period of the study with an average rate of hand hygiene compliance of 87.9%. The improvement in hand hygiene compliance required active provision of feedback as well as the presence of monitoring equipment, making the applicability of this study limited, based on the cost of the technology and the manpower to provide feedback.

Bottom line: Hand hygiene practices improve when healthcare workers are given immediate feedback on their compliance.

Citation: Rebellion D, Husain E, Schilling ME, et al. Using high-technology to enforce low-technology safety measures: the use of third-party remote video auditing and real-time feedback in healthcare. Clin Infect Dis. 2012:54(1):1-7.

Mismanagement of Enterococcal Bacteriuria

Clinical question: Are clinical providers following appropriate guidelines to identify and manage enterococcal bacteriuria?

Background: There are specific evidence-based guidelines for the diagnosis and treatment of urinary tract infections (UTI) and asymptomatic bacteriuria (ABU). ABU is often mistaken for a UTI, and incorrectly treated as one.

Study design: Retrospective cohort.

Setting: Two academic teaching hospitals in Houston, Texas.

Synopsis: Using the current Infectious Disease Society of America (IDSA) guidelines, 375 Enterococcus urine cultures were reviewed and determined to be either UTI or ABU. The cultures were initially reviewed for appropriate treatment and again 30 days later for complications. UTI was defined as bacteriuria with one or more sign or symptom (urgency, frequency, dysuria, suprapubic tenderness, flank pain, rigors, visible hematuria, delirium, or fevers) without another identifiable cause. ABU was defined as bacteriuria without any of the signs or symptoms, or a clear nonurinary source.

Of the 339 cultures matching inclusion criteria, 156 were classified as UTI and 183 classified as ABU. Sixty of the 183 ABU (32.8%) were inappropriately treated with antibiotics, while antibiotics were withheld in 23 of the 156 UTI (14.7%). Eighty-three of 339 cultures (24.5%) were incorrectly treated. The most common reason for ABU being inappropriately treated was the presence of pyuria, associated with a threefold higher use of antibiotics.

There was no significant difference in subsequent infections or infectious complications between UTI and ABU.

Bottom line: Enterococcal ABU is frequently treated with antibiotics, even though guidelines recommend against it; providers should resist overtreating enterococcal ABU.

Citation: Lin E, Bhusal Y, Horwitz D, Shelburne SA, Trautner BW. Overtreatment of enterococcal bacteriuria. Arch Intern Med. 2012;172:33-38.

CT Angiography for the Diagnosis of Acute Lower GI Bleeding in an Emergency Setting

Clinical question: Is CT angiography a reliable initial diagnostic procedure to identify the presence and location of an acute lower gastrointestinal (GI) bleed in the ED setting?

Background: CT angiography has been identified as a potentially useful procedure to identify acute GI bleeds; however, the specific role and timing of the procedure has not been clearly identified.

Study design: Prospective study.

Setting: ED of a university-based hospital in Madrid.

Synopsis: CT angiography was performed on 47 ED patients (27 men, 20 women, with a mean age of 68 years) with an acute lower GI bleed. Study protocol included a preliminary unenhanced CT scan followed by CT angiogram prior to the standard clinical protocol, which included colonoscopy, angiography, or laparotomy.

Images were reviewed by two different ED radiologists, who were blinded to the diagnosis, and compared with the standard protocol findings. CT angiography correctly identified active acute or recent GI bleeding in 46 of the 47 patients, with a sensitivity of 100% (19 of 19), NPV of 100% (27 of 27), specificity of 96% (27 of 28), and PPV of 95% (19 of 20). CT angiography also was 93% accurate in identifying the cause of the GI bleed when compared with the standard reference.

Limitations of the study include its small size and the lack of a control group.

Bottom line: CT angiography is an accurate and more readily available modality for the diagnosis of acute lower GI bleeding, though it does not provide a therapeutic option.

Citation: Martí M, Artigas JM, Garzón G, Alvarez-Sala R, Soto JA. Acute lower intestinal bleeding: feasibility and diagnostic performance of CT angiography. Radiology. 2012;262:109-116.

Substitution of Levalbuterol to Avoid Tachyarrhythmia Not Supported

Clinical question: Does substitution of levalbuterol for albuterol in critically ill adult patients result in decreased incidence of tachyarrhythmias?

Background: Studies have indicated an increased risk of mortality from tachycardia and tachyarrhythmias in ICU patients. Levalbuterol is the R-isomer of albuterol, and it has been proposed that it may mitigate cardiac side effects seen with beta-2 agonists. For this reason, some clinicians have advocated using nebulized levalbuterol in critically ill patients.

Study design: Prospective randomized controlled trial with patient crossover.

Setting: Single academic medical center.

Synopsis: All ICU patients in a single teaching hospital were screened, and 70 patients were included. Patients were randomly crossed over between albuterol and levalbuterol every four to six hours. This resulted in a total of 836 measurements of heart rate, the primary outcome measurement. The study showed no clinically significant differences in average heart rate when using levalbuterol versus albuterol. This was a small study of ICU patients, using a surrogate endpoint of heart rate rather than mortality. Furthermore, the assessment of tachyarrhythmias was limited given the study size and relative rarity of these events. Despite these limitations, the study casts significant doubt on the theory and practice of switching from albuterol to levalbuterol solely for the purpose of reducing or avoiding tachycardia or tachyarrhythmias.

Bottom line: Substitution of levalbuterol for albuterol to avert tachycardia in critically ill patients is not warranted.

Citation: Khorfan FM, Smith P, Watt S, Barber KR. Effects of nebulized bronchodilator therapy on heart rate and arrhythmias in critically ill adult patients. Chest. 2011;140:1466-1472.

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Online calculator helps prevent post-op respiratory failure
2. New drug for long-term treatment of PE
3. Benefits of triple therapy for COPD
4. Knee-length compression stockings as good as thigh-length for PTS
5. Video monitoring improves hand hygiene
6. Asymptomatic bacteriuria often misdiagnosed as UTI
7. CT accurate for lower GI bleeding diagnosis
8. Switch from albuterol to lavalbuterol to reduce tachycardia not recommended

Preoperative Risk Calculator Can Help Predict Postoperative Respiratory Failure

Clinical question: Can preoperative factors identify patients at risk for postoperative respiratory failure (PRF)?

Background: PRF—when a patient requires mechanical ventilation >48 hours after surgery or needs unplanned intubation within 30 days of surgery—is associated with high mortality, with 30-day mortality rates of 26%.

Study design: Analysis of multicenter, prospective databases of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP).

Setting: Analysis of NSQIP data from 2007 (training set) and 2008 (validation set).

Synopsis: PRF was seen in 3.1% of patients in the 2007 data set and 2.6% in the 2008 data set. Those with PRF had significantly higher mortality rates than those without PRF (25.62% vs. 0.98%; P<0.0001). Preoperative risk factors associated with significantly increased risk of PRF were American Society of Anesthesiologists’ class, functional status, emergent nature of procedure, type of surgery, and preoperative sepsis.

The 2007 data set was used to develop the model, and the 2008 data set was used as a validation set. The selected risk model showed similar results in both sets with a c-statistic of 0.91 in the training set and 0.90 in the validation set. This selected model was then used to develop an interactive calculator predicting PRF (available at www.surgicalriskcalculator.com/prf-risk-calculator).

Bottom line: The PRF risk calculator can identify patients at high risk for PRF, which can aid in tailoring preventive strategies for patients prior to surgery.

Citation: Gupta H, Gupta PK, Fang X, et al. Development and validation of a risk calculator predicting postoperative respiratory failure. Chest. 2011;140:1207-1215.

New Drug for Treatment of Acute Symptomatic Pulmonary Embolism

Clinical question: Is the incidence of recurrent venous thromboembolism (VTE) or bleeding with use of idrabiotaparinux comparable to warfarin for treatment of acute symptomatic pulmonary embolism (PE)?

Background: Warfarin is an effective treatment for PE; however, maintenance of effective and safe levels of anticoagulation is difficult to achieve. A straightforward treatment option would be an attractive alternative. Idrabiotaparinux, a factor Xa inhibitor bound with a biotin moiety, is a weekly subcutaneous injection proposed as an alternative to warfarin for treatment of PE.

Study design: Industry-sponsored double-blind, randomized controlled trial.

Setting: 291 centers in 37 countries.

Synopsis: A group of 3,202 patients aged 18 to 96 years were randomly assigned to receive enoxaparin, followed by idrabiotaparinux or enoxaparin, then overlapped and followed by warfarin for three or six months. The incidence of recurrent VTE (including fatal and nonfatal PE or deep vein thrombosis) did not differ between the two treatment arms.

Of the 1,599 patients treated with idrabiotaparinux, 48 (3%) had a recurrence; of the 1,603 treated with warfarin, 97 (6%) had a recurrence (odds ratio, 0.49). The rate of clinically relevant bleeding was also similar, with 72 (5%) in the idrabiotaparinux group versus 106 (7%) in the warfarin group. Much like warfarin, idrabiotaparinux requires bridging therapy with initial low-molecular-weight heparin.

Bottom line: Use of enoxaparin followed by weekly subcutaneous injection of idrabiotaparinux was as effective as enoxaparin followed by warfarin for preventing recurrent VTE, and may provide a suitable option for treatment of acute symptomatic PE.

Citation: Buller HR, Gallus AS, Pillion G, Prins MH, Raskob GE. Enoxaparin followed by once-weekly idrabiotaparinux versus enoxaparin plus warfarin for patients with acute symptomatic pulmonary embolism: a randomised, double-blind, double-dummy, non-inferiority trial. Lancet. 2012;379:123-129.

Triple Therapy Better than Double for COPD

Clinical question: Does addition of tiotropium to inhaled corticosteroids and long-acting beta-agonists (LABA) have an additive benefit in reducing mortality, hospital admissions, and exacerbations in COPD?

Background: Triple therapy in COPD involves adding LABA and long-acting antimuscarinics (LAMA), such as tiotropium, to inhaled corticosteroids (ICS). Despite the guidelines recommending triple therapy for severe COPD, most studies have evaluated either LAMA or LABA plus ICS, but not all three together.

Study design: Retrospective cohort.

Setting: Tayside, Scotland’s National Health Services database.

Synopsis: Patients with severe COPD were divided into two groups: 1,857 patients had received ICS+LABA (double therapy) and 996 had received ICS+LABA+tiotropium (triple therapy), with follow-up of 4.65 years.

All-cause mortality was 35% lower in the triple therapy group (HR 0.65, 95% CI 0.57-0.75). Corticosteroid use was 29% lower (HR 0.71, 95% CI 0.63-0.80), and hospital admissions were 15% lower (HR 0.85, 95% CI 0.73-0.99) in the triple-therapy group. These results were adjusted for smoking, age, sex, socioeconomic status, and history of diabetes, cardiovascular, and respiratory disease.

This study is limited by its observational retrospective design but provides good evidence of the need for randomized controlled trials to validate the clinical benefits of triple therapy.

Bottom line: Adding tiotropium to ICS plus LABA is associated with lower all-cause mortality, hospitalizations, and corticosteroid use when compared with ICS plus LABA, validating its current use in management of severe COPD.

Citation: Short PM, Williamson PA, Elder DHJ, Lipworth SIW, Schembi S, Lipworth BJ. The impact of tiotropium on mortality and exacerbations when added to inhaled corticosteroids and long-acting β-agonist therapy in COPD. Chest. 2012;141:81-86.

Above-Knee Compression Stockings Not Better than Below-Knee Stockings for Protection Against Post-Thrombotic Syndrome

Clinical question: Do above-knee compression elastic stockings prevent post-thrombotic syndrome (PTS) better than below-knee stockings?

Background: PTS—characterized by leg pain, cramps, edema, and hyperpigmentation—occurs in 25% to 50% of patients after an episode of deep venous thrombosis (DVT). Previous studies demonstrated a 50% reduction in the incidence of PTS when patients used below-knee stockings.

Study design: Open-label, randomized clinical trial.

Setting: Eight hospitals in Italy.

Synopsis: A total of 267 patients with their first episode of DVT were randomized to thigh-length or below-knee compression elastic stockings, as well as therapeutic anticoagulation, with a primary endpoint of three-year incidence of PTS. Assessment was done by study personnel who were blinded to the type of stocking the patients had been prescribed. Severity of PTS was graded by a scoring system incorporating objective and subjective criteria with an independent adjudicator.

The intention-to-treat analysis showed no significant difference in the three-year incidence of PTS between thigh- and knee-length stockings (32.6% vs. 35.6%, respectively). Compliance was better in the knee-length (82.6%) than in the thigh-length (66.7%) group due to the significantly lower rate of stockings-related side effects.

The study is limited by a lack of blinding in the study participants.

Bottom line: Knee-length stockings offer equal similar protection against PTS with better compliance when compared with thigh-length stockings.

Citation: Prandoni P, Noventa F, Quintavalla R, et al. Thigh-length versus below-knee compression elastic stockings for prevention of the post-thrombotic syndrome in patients with proximal-venous thrombosis: a randomized trial. Blood. 2012;119:1561-1565.

Video Auditing With Near- Real-Time Feedback Improves Hand Hygiene Practices

Clinical question: Does the use of direct video monitoring with continuous, multi-modal feedback promote improvement in healthcare workers’ compliance with hand hygiene?

Background: Appropriate hand hygiene is an effective means of infection control. Direct human observation of hand hygiene compliance does little more than provide a biased, temporary, and often overestimated assessment of compliance. The use of video-based monitoring technology in other aspects of society (e.g. traffic signal cameras) has been well demonstrated to modify behavior.

Study design: Prospective cohort study.

Setting: Tertiary-care hospital’s 17-bed medical ICU in the northeastern U.S.

Synopsis: Through the use of 21 motion-activated video cameras with continuous third-party auditing, the provision of near real-time feedback improved hand hygiene rates of healthcare workers from 6.5% to 81.6%. In the four months preceding feedback, only 3,933 hand-washing events out of 60,542 (6.5%) were considered “passing.” During the active feedback period, 59,627 events out of 73,080 (81.6%) passed.

The improvement was sustained in the maintenance period of the study with an average rate of hand hygiene compliance of 87.9%. The improvement in hand hygiene compliance required active provision of feedback as well as the presence of monitoring equipment, making the applicability of this study limited, based on the cost of the technology and the manpower to provide feedback.

Bottom line: Hand hygiene practices improve when healthcare workers are given immediate feedback on their compliance.

Citation: Rebellion D, Husain E, Schilling ME, et al. Using high-technology to enforce low-technology safety measures: the use of third-party remote video auditing and real-time feedback in healthcare. Clin Infect Dis. 2012:54(1):1-7.

Mismanagement of Enterococcal Bacteriuria

Clinical question: Are clinical providers following appropriate guidelines to identify and manage enterococcal bacteriuria?

Background: There are specific evidence-based guidelines for the diagnosis and treatment of urinary tract infections (UTI) and asymptomatic bacteriuria (ABU). ABU is often mistaken for a UTI, and incorrectly treated as one.

Study design: Retrospective cohort.

Setting: Two academic teaching hospitals in Houston, Texas.

Synopsis: Using the current Infectious Disease Society of America (IDSA) guidelines, 375 Enterococcus urine cultures were reviewed and determined to be either UTI or ABU. The cultures were initially reviewed for appropriate treatment and again 30 days later for complications. UTI was defined as bacteriuria with one or more sign or symptom (urgency, frequency, dysuria, suprapubic tenderness, flank pain, rigors, visible hematuria, delirium, or fevers) without another identifiable cause. ABU was defined as bacteriuria without any of the signs or symptoms, or a clear nonurinary source.

Of the 339 cultures matching inclusion criteria, 156 were classified as UTI and 183 classified as ABU. Sixty of the 183 ABU (32.8%) were inappropriately treated with antibiotics, while antibiotics were withheld in 23 of the 156 UTI (14.7%). Eighty-three of 339 cultures (24.5%) were incorrectly treated. The most common reason for ABU being inappropriately treated was the presence of pyuria, associated with a threefold higher use of antibiotics.

There was no significant difference in subsequent infections or infectious complications between UTI and ABU.

Bottom line: Enterococcal ABU is frequently treated with antibiotics, even though guidelines recommend against it; providers should resist overtreating enterococcal ABU.

Citation: Lin E, Bhusal Y, Horwitz D, Shelburne SA, Trautner BW. Overtreatment of enterococcal bacteriuria. Arch Intern Med. 2012;172:33-38.

CT Angiography for the Diagnosis of Acute Lower GI Bleeding in an Emergency Setting

Clinical question: Is CT angiography a reliable initial diagnostic procedure to identify the presence and location of an acute lower gastrointestinal (GI) bleed in the ED setting?

Background: CT angiography has been identified as a potentially useful procedure to identify acute GI bleeds; however, the specific role and timing of the procedure has not been clearly identified.

Study design: Prospective study.

Setting: ED of a university-based hospital in Madrid.

Synopsis: CT angiography was performed on 47 ED patients (27 men, 20 women, with a mean age of 68 years) with an acute lower GI bleed. Study protocol included a preliminary unenhanced CT scan followed by CT angiogram prior to the standard clinical protocol, which included colonoscopy, angiography, or laparotomy.

Images were reviewed by two different ED radiologists, who were blinded to the diagnosis, and compared with the standard protocol findings. CT angiography correctly identified active acute or recent GI bleeding in 46 of the 47 patients, with a sensitivity of 100% (19 of 19), NPV of 100% (27 of 27), specificity of 96% (27 of 28), and PPV of 95% (19 of 20). CT angiography also was 93% accurate in identifying the cause of the GI bleed when compared with the standard reference.

Limitations of the study include its small size and the lack of a control group.

Bottom line: CT angiography is an accurate and more readily available modality for the diagnosis of acute lower GI bleeding, though it does not provide a therapeutic option.

Citation: Martí M, Artigas JM, Garzón G, Alvarez-Sala R, Soto JA. Acute lower intestinal bleeding: feasibility and diagnostic performance of CT angiography. Radiology. 2012;262:109-116.

Substitution of Levalbuterol to Avoid Tachyarrhythmia Not Supported

Clinical question: Does substitution of levalbuterol for albuterol in critically ill adult patients result in decreased incidence of tachyarrhythmias?

Background: Studies have indicated an increased risk of mortality from tachycardia and tachyarrhythmias in ICU patients. Levalbuterol is the R-isomer of albuterol, and it has been proposed that it may mitigate cardiac side effects seen with beta-2 agonists. For this reason, some clinicians have advocated using nebulized levalbuterol in critically ill patients.

Study design: Prospective randomized controlled trial with patient crossover.

Setting: Single academic medical center.

Synopsis: All ICU patients in a single teaching hospital were screened, and 70 patients were included. Patients were randomly crossed over between albuterol and levalbuterol every four to six hours. This resulted in a total of 836 measurements of heart rate, the primary outcome measurement. The study showed no clinically significant differences in average heart rate when using levalbuterol versus albuterol. This was a small study of ICU patients, using a surrogate endpoint of heart rate rather than mortality. Furthermore, the assessment of tachyarrhythmias was limited given the study size and relative rarity of these events. Despite these limitations, the study casts significant doubt on the theory and practice of switching from albuterol to levalbuterol solely for the purpose of reducing or avoiding tachycardia or tachyarrhythmias.

Bottom line: Substitution of levalbuterol for albuterol to avert tachycardia in critically ill patients is not warranted.

Citation: Khorfan FM, Smith P, Watt S, Barber KR. Effects of nebulized bronchodilator therapy on heart rate and arrhythmias in critically ill adult patients. Chest. 2011;140:1466-1472.

Clinical question: What is the association between childhood urinary tract infections (UTIs) and chronic kidney disease (CKD)?

Background: A traditional paradigm in pediatrics is that CKD might be caused by renal scarring as a result of recurrent UTIs, particularly in the presence of vesicoureteral reflux (VUR). Increasingly, this has been called into question as nonintervention for low-grade VUR has not impacted clinical outcomes.

Study design: Retrospective cohort and systematic literature review.

Setting: Tertiary-care hospital in Finland and PubMed database.

Synopsis: A search of the PubMed database for articles published from 1966 to 2009 relating to a potential association between CKD and UTIs yielded 10 studies reporting on 1,576 patients with UTIs and long-term evaluation for CKD. Only three of the 1,576 patients had childhood UTIs without structural kidney abnormalities as a potential cause of the CKD. VUR was not considered a structural abnormality. The authors note that no data on kidney morphology prior to UTI recurrence were available in these cases.

At the same time, the study authors reviewed the records of 366 patients with CKD at a tertiary-care hospital in Finland. They excluded 308 patients with defined noninfectious causes of CKD. Of the 58 remaining patients, three potentially had recurrent UTIs as a contributing cause to eventual CKD. All three patients had structurally abnormal kidneys on first radiologic examination, possibly suggesting pre-existing renal anomalies. The potential association between recurrent childhood UTIs without structural abnormalities and CKD appears to be less than 1%.

Limitations of this study include its retrospective design and incomplete characterization systematic review. Nevertheless, the study appears to support recent work that childhood UTIs without underlying kidney abnormalities are unlikely to result in permanent renal damage.

Bottom line: Childhood UTIs, without structural kidney abnormality, are not a significant cause of chronic kidney disease in adults.

Citation: Salo J, Ilkäheimo R, Tapiainen T, Uhari M. Childhood urinary tract infections as a cause of chronic kidney disease. Pediatrics. 2011;128:840-847.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What is the association between childhood urinary tract infections (UTIs) and chronic kidney disease (CKD)?

Background: A traditional paradigm in pediatrics is that CKD might be caused by renal scarring as a result of recurrent UTIs, particularly in the presence of vesicoureteral reflux (VUR). Increasingly, this has been called into question as nonintervention for low-grade VUR has not impacted clinical outcomes.

Study design: Retrospective cohort and systematic literature review.

Setting: Tertiary-care hospital in Finland and PubMed database.

Synopsis: A search of the PubMed database for articles published from 1966 to 2009 relating to a potential association between CKD and UTIs yielded 10 studies reporting on 1,576 patients with UTIs and long-term evaluation for CKD. Only three of the 1,576 patients had childhood UTIs without structural kidney abnormalities as a potential cause of the CKD. VUR was not considered a structural abnormality. The authors note that no data on kidney morphology prior to UTI recurrence were available in these cases.

At the same time, the study authors reviewed the records of 366 patients with CKD at a tertiary-care hospital in Finland. They excluded 308 patients with defined noninfectious causes of CKD. Of the 58 remaining patients, three potentially had recurrent UTIs as a contributing cause to eventual CKD. All three patients had structurally abnormal kidneys on first radiologic examination, possibly suggesting pre-existing renal anomalies. The potential association between recurrent childhood UTIs without structural abnormalities and CKD appears to be less than 1%.

Limitations of this study include its retrospective design and incomplete characterization systematic review. Nevertheless, the study appears to support recent work that childhood UTIs without underlying kidney abnormalities are unlikely to result in permanent renal damage.

Bottom line: Childhood UTIs, without structural kidney abnormality, are not a significant cause of chronic kidney disease in adults.

Citation: Salo J, Ilkäheimo R, Tapiainen T, Uhari M. Childhood urinary tract infections as a cause of chronic kidney disease. Pediatrics. 2011;128:840-847.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Clinical question: What is the association between childhood urinary tract infections (UTIs) and chronic kidney disease (CKD)?

Background: A traditional paradigm in pediatrics is that CKD might be caused by renal scarring as a result of recurrent UTIs, particularly in the presence of vesicoureteral reflux (VUR). Increasingly, this has been called into question as nonintervention for low-grade VUR has not impacted clinical outcomes.

Study design: Retrospective cohort and systematic literature review.

Setting: Tertiary-care hospital in Finland and PubMed database.

Synopsis: A search of the PubMed database for articles published from 1966 to 2009 relating to a potential association between CKD and UTIs yielded 10 studies reporting on 1,576 patients with UTIs and long-term evaluation for CKD. Only three of the 1,576 patients had childhood UTIs without structural kidney abnormalities as a potential cause of the CKD. VUR was not considered a structural abnormality. The authors note that no data on kidney morphology prior to UTI recurrence were available in these cases.

At the same time, the study authors reviewed the records of 366 patients with CKD at a tertiary-care hospital in Finland. They excluded 308 patients with defined noninfectious causes of CKD. Of the 58 remaining patients, three potentially had recurrent UTIs as a contributing cause to eventual CKD. All three patients had structurally abnormal kidneys on first radiologic examination, possibly suggesting pre-existing renal anomalies. The potential association between recurrent childhood UTIs without structural abnormalities and CKD appears to be less than 1%.

Limitations of this study include its retrospective design and incomplete characterization systematic review. Nevertheless, the study appears to support recent work that childhood UTIs without underlying kidney abnormalities are unlikely to result in permanent renal damage.

Bottom line: Childhood UTIs, without structural kidney abnormality, are not a significant cause of chronic kidney disease in adults.

Citation: Salo J, Ilkäheimo R, Tapiainen T, Uhari M. Childhood urinary tract infections as a cause of chronic kidney disease. Pediatrics. 2011;128:840-847.

Reviewed by Pediatric Editor Mark Shen, MD, FHM, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.

Background

Uncomplicated cystitis is one of the most common indications for prescribing antimicrobial therapy to otherwise healthy women, but wide variation in prescribing practices has been described.^1-2 This has prompted the need for guidelines to help providers in their selection of empiric antimicrobial regimens. Antibiotic selection should take into consideration the efficacy of individual agents, as well as their propensity for inducing resistance, altering gut flora, and increasing the risk of colonization or infection with multi-drug resistant organisms.

Guideline Update

In March 2010, the Infectious Diseases Society of America (IDSA) and the European Society for Microbiology and Infectious Diseases (ESCMID) published new guidelines for the treatment of uncomplicated cystitis and pyelonephritis in healthy, community-dwelling women.³

First-line recommended agents for empiric treatment of uncomplicated cystitis are:

• nitrofurantoin for five days;
• trimethoprim-sulfamethoxazole for three days;
• fosfomycin in a single dose; or
• pivmecillinam (where available) for three to seven days.

Although highly efficacious, fluoroquinolones are not recommended as first-line treatment for acute cystitis because of their propensity for causing “collateral damage,” especially alteration of gut flora and increased risk of multi-drug resistant infection or colonization, including methicillin-resistant Staphylococcus aureus. Oral beta-lactams (other than pivmecillinam) have generally demonstrated inferior efficacy and more adverse effects when compared with the above agents, and should be used only if none of the preferred agents can be used. Specifically, amoxicillin and ampicillin are not recommended as empiric therapy due to their low efficacy in unselected patients, though may be appropriate when culture data is available to guide therapy. Narrow spectrum cephalosporins are also a potential agent for use in certain clinical situations, although the guidelines do not make any recommendation for or against their use, given a lack of studies.

For the treatment of acute pyelonephritis, the guidelines emphasize that all patients should have urine culture and susceptibility testing in order to tailor empiric therapy to the specific uropathogen. A 5-7 day course of an oral fluoroquinolone is appropriate when the prevalence of resistance in community uropathogens is ≤10%. Where resistance is more common, an initial intravenous dose of ceftriaxone or an aminoglycoside can be administered prior to starting oral therapy. Other alternatives include a 14-day course of trimethoprim-sulfamethoxazole or an oral beta-lactam.

Women requiring hospitalization for pyelonephritis should initially be treated with an intravenous antimicrobial regimen, the choice of which should be based on local resistance patterns. Recommended intravenous agents include fluoroquinolones, aminoglycosides (with or without ampicillin), extended-spectrum cephalosporins / penicillins, or carbapenems.

Analysis

Previous guidelines for the treatment of uncomplicated cystitis and pyelonephritis were published by the IDSA in 1999.⁴ The guidelines were updated based on the following factors:

• continued variability in prescribing practices;1-2
• increase in antimicrobial resistance among uropathogens;
• awareness of the unintended consequences of antimicrobial therapy, such as selection of drug-resistant organisms and colonization or infection with multi-drug resistant organisms; and
• study of newer agents and different durations of therapy.

Two important differences exist between the 1999 and 2010 guidelines:

• Nitrofurantoin has taken on more prominence in the 2010 guidelines for uncomplicated cystitis. The 1999 guidelines recommended trimethoprim-sulfamethoxazole as a first-line agent and mentioned nitrofurantoin and fosfomycin as potential alternative agents, but had few studies available to inform comparative efficacy or duration of therapy.
• For the outpatient treatment of mildly-ill patients with acute pyelonephritis, the 1999 guidelines recommended 14 days of therapy regardless of the agent used; in contrast, the 2010 guidelines recommend a five- to seven-day course for oral fluoroquinolones.

The American Congress of Obstetricians and Gynecologists, American Urological Association, Association of Medical Microbiology and Infectious Diseases-Canada, and the Society for Academic Emergency Medicine have endorsed the 2010 IDSA-ESCMID guidelines. The IDSA and ESCMID plan to evaluate the need for revisions to the 2010 guidelines based on an annual review of the current literature.

HM Takeaways

The 2010 IDSA-ESCMID guidelines are a resource available to hospitalists treating acute uncomplicated cystitis and pyelonephritis. As important differences exist between the target population and the hospitalist’s patient population, there are some key points to consider for clinicians treating cystitis or pyelonephritis in hospitalized patients.

Importantly, while nitrofurantoin is favored as a first-line antimicrobial agent for cystitis in the 2010 IDSA-ESCMID guidelines, it might be problematic in hospitalized patients for several reasons:

• it is not approved or recommended for the treatment of pyelonephritis;
• it is contraindicated in patients with creatinine clearance <60 ml/min; and
• it is generally not recommended for use in patients >65 years old because of the risk of renal impairment (Beers Criteria).⁵

Additionally, the treatment of acute cystitis in men requires special consideration. Notably, nitrofurantoin is not recommended in men because of poor prostatic tissue penetration, and although studies are limited, some sources recommend a longer treatment duration of at least 7 days.⁶ Finally, hospitalized patients commonly have other conditions, such as urological abnormalities, indwelling Foley catheters, recent urinary tract instrumentation, recent use of antibiotics, risk for multi-drug resistant organisms, potential interactions with other medications, and immunosuppression. The presence of any of these factors will influence the choice of empiric therapy and may warrant treatment for complicated cystitis or pyelonephritis, which are not addressed by these guidelines.

Drs. Tarvin and Sponsler are academic hospitalists at Vanderbilt University School of Medicine in Nashville, Tenn.

References

1. Huang ES, Stafford RS. National patterns in the treatment of urinary tract infections in women by ambulatory care physicians. Arch Intern Med. 2006;166:635-639.
2. Kahan NR, Chinitz DP, Kahan E. Longer than recommended empiric antibiotic treatment of urinary tract infection in women: an avoidable waste of money. J Clin Pharm Therap. 2004;29:59-63.
3. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Inf Dis. 2011;52(5):e103-20.
4. Warren JW, Abrutyn E, Hebel JR, Schaeffer AJ, Stamm WE. Guidelines for antimicrobial treatment of acute bacterial cystitis and acute pyelonephritis in women. Infectious Diseases Society of America. Clin Inf Dis. 1999;29(4):745-58.
5. Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a U.S. consensus panel of experts. Arch Intern Med. 2003;163(22):2716-2724.
6. Mehnert-Kay SA. Diagnosis and management of uncomplicated urinary tract infections. A Fam Phys. 2005;72(3):451-456.

Background

Uncomplicated cystitis is one of the most common indications for prescribing antimicrobial therapy to otherwise healthy women, but wide variation in prescribing practices has been described.^1-2 This has prompted the need for guidelines to help providers in their selection of empiric antimicrobial regimens. Antibiotic selection should take into consideration the efficacy of individual agents, as well as their propensity for inducing resistance, altering gut flora, and increasing the risk of colonization or infection with multi-drug resistant organisms.

Guideline Update

In March 2010, the Infectious Diseases Society of America (IDSA) and the European Society for Microbiology and Infectious Diseases (ESCMID) published new guidelines for the treatment of uncomplicated cystitis and pyelonephritis in healthy, community-dwelling women.³

First-line recommended agents for empiric treatment of uncomplicated cystitis are:

• nitrofurantoin for five days;
• trimethoprim-sulfamethoxazole for three days;
• fosfomycin in a single dose; or
• pivmecillinam (where available) for three to seven days.

Although highly efficacious, fluoroquinolones are not recommended as first-line treatment for acute cystitis because of their propensity for causing “collateral damage,” especially alteration of gut flora and increased risk of multi-drug resistant infection or colonization, including methicillin-resistant Staphylococcus aureus. Oral beta-lactams (other than pivmecillinam) have generally demonstrated inferior efficacy and more adverse effects when compared with the above agents, and should be used only if none of the preferred agents can be used. Specifically, amoxicillin and ampicillin are not recommended as empiric therapy due to their low efficacy in unselected patients, though may be appropriate when culture data is available to guide therapy. Narrow spectrum cephalosporins are also a potential agent for use in certain clinical situations, although the guidelines do not make any recommendation for or against their use, given a lack of studies.

For the treatment of acute pyelonephritis, the guidelines emphasize that all patients should have urine culture and susceptibility testing in order to tailor empiric therapy to the specific uropathogen. A 5-7 day course of an oral fluoroquinolone is appropriate when the prevalence of resistance in community uropathogens is ≤10%. Where resistance is more common, an initial intravenous dose of ceftriaxone or an aminoglycoside can be administered prior to starting oral therapy. Other alternatives include a 14-day course of trimethoprim-sulfamethoxazole or an oral beta-lactam.

Women requiring hospitalization for pyelonephritis should initially be treated with an intravenous antimicrobial regimen, the choice of which should be based on local resistance patterns. Recommended intravenous agents include fluoroquinolones, aminoglycosides (with or without ampicillin), extended-spectrum cephalosporins / penicillins, or carbapenems.

Analysis

Previous guidelines for the treatment of uncomplicated cystitis and pyelonephritis were published by the IDSA in 1999.⁴ The guidelines were updated based on the following factors:

• continued variability in prescribing practices;1-2
• increase in antimicrobial resistance among uropathogens;
• awareness of the unintended consequences of antimicrobial therapy, such as selection of drug-resistant organisms and colonization or infection with multi-drug resistant organisms; and
• study of newer agents and different durations of therapy.

Two important differences exist between the 1999 and 2010 guidelines:

• Nitrofurantoin has taken on more prominence in the 2010 guidelines for uncomplicated cystitis. The 1999 guidelines recommended trimethoprim-sulfamethoxazole as a first-line agent and mentioned nitrofurantoin and fosfomycin as potential alternative agents, but had few studies available to inform comparative efficacy or duration of therapy.
• For the outpatient treatment of mildly-ill patients with acute pyelonephritis, the 1999 guidelines recommended 14 days of therapy regardless of the agent used; in contrast, the 2010 guidelines recommend a five- to seven-day course for oral fluoroquinolones.

The American Congress of Obstetricians and Gynecologists, American Urological Association, Association of Medical Microbiology and Infectious Diseases-Canada, and the Society for Academic Emergency Medicine have endorsed the 2010 IDSA-ESCMID guidelines. The IDSA and ESCMID plan to evaluate the need for revisions to the 2010 guidelines based on an annual review of the current literature.

HM Takeaways

The 2010 IDSA-ESCMID guidelines are a resource available to hospitalists treating acute uncomplicated cystitis and pyelonephritis. As important differences exist between the target population and the hospitalist’s patient population, there are some key points to consider for clinicians treating cystitis or pyelonephritis in hospitalized patients.

Importantly, while nitrofurantoin is favored as a first-line antimicrobial agent for cystitis in the 2010 IDSA-ESCMID guidelines, it might be problematic in hospitalized patients for several reasons:

• it is not approved or recommended for the treatment of pyelonephritis;
• it is contraindicated in patients with creatinine clearance <60 ml/min; and
• it is generally not recommended for use in patients >65 years old because of the risk of renal impairment (Beers Criteria).⁵

Additionally, the treatment of acute cystitis in men requires special consideration. Notably, nitrofurantoin is not recommended in men because of poor prostatic tissue penetration, and although studies are limited, some sources recommend a longer treatment duration of at least 7 days.⁶ Finally, hospitalized patients commonly have other conditions, such as urological abnormalities, indwelling Foley catheters, recent urinary tract instrumentation, recent use of antibiotics, risk for multi-drug resistant organisms, potential interactions with other medications, and immunosuppression. The presence of any of these factors will influence the choice of empiric therapy and may warrant treatment for complicated cystitis or pyelonephritis, which are not addressed by these guidelines.

Drs. Tarvin and Sponsler are academic hospitalists at Vanderbilt University School of Medicine in Nashville, Tenn.

References

1. Huang ES, Stafford RS. National patterns in the treatment of urinary tract infections in women by ambulatory care physicians. Arch Intern Med. 2006;166:635-639.
2. Kahan NR, Chinitz DP, Kahan E. Longer than recommended empiric antibiotic treatment of urinary tract infection in women: an avoidable waste of money. J Clin Pharm Therap. 2004;29:59-63.
3. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Inf Dis. 2011;52(5):e103-20.
4. Warren JW, Abrutyn E, Hebel JR, Schaeffer AJ, Stamm WE. Guidelines for antimicrobial treatment of acute bacterial cystitis and acute pyelonephritis in women. Infectious Diseases Society of America. Clin Inf Dis. 1999;29(4):745-58.
5. Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a U.S. consensus panel of experts. Arch Intern Med. 2003;163(22):2716-2724.
6. Mehnert-Kay SA. Diagnosis and management of uncomplicated urinary tract infections. A Fam Phys. 2005;72(3):451-456.

Background

Uncomplicated cystitis is one of the most common indications for prescribing antimicrobial therapy to otherwise healthy women, but wide variation in prescribing practices has been described.^1-2 This has prompted the need for guidelines to help providers in their selection of empiric antimicrobial regimens. Antibiotic selection should take into consideration the efficacy of individual agents, as well as their propensity for inducing resistance, altering gut flora, and increasing the risk of colonization or infection with multi-drug resistant organisms.

Guideline Update

In March 2010, the Infectious Diseases Society of America (IDSA) and the European Society for Microbiology and Infectious Diseases (ESCMID) published new guidelines for the treatment of uncomplicated cystitis and pyelonephritis in healthy, community-dwelling women.³

First-line recommended agents for empiric treatment of uncomplicated cystitis are:

• nitrofurantoin for five days;
• trimethoprim-sulfamethoxazole for three days;
• fosfomycin in a single dose; or
• pivmecillinam (where available) for three to seven days.

Although highly efficacious, fluoroquinolones are not recommended as first-line treatment for acute cystitis because of their propensity for causing “collateral damage,” especially alteration of gut flora and increased risk of multi-drug resistant infection or colonization, including methicillin-resistant Staphylococcus aureus. Oral beta-lactams (other than pivmecillinam) have generally demonstrated inferior efficacy and more adverse effects when compared with the above agents, and should be used only if none of the preferred agents can be used. Specifically, amoxicillin and ampicillin are not recommended as empiric therapy due to their low efficacy in unselected patients, though may be appropriate when culture data is available to guide therapy. Narrow spectrum cephalosporins are also a potential agent for use in certain clinical situations, although the guidelines do not make any recommendation for or against their use, given a lack of studies.

For the treatment of acute pyelonephritis, the guidelines emphasize that all patients should have urine culture and susceptibility testing in order to tailor empiric therapy to the specific uropathogen. A 5-7 day course of an oral fluoroquinolone is appropriate when the prevalence of resistance in community uropathogens is ≤10%. Where resistance is more common, an initial intravenous dose of ceftriaxone or an aminoglycoside can be administered prior to starting oral therapy. Other alternatives include a 14-day course of trimethoprim-sulfamethoxazole or an oral beta-lactam.

Women requiring hospitalization for pyelonephritis should initially be treated with an intravenous antimicrobial regimen, the choice of which should be based on local resistance patterns. Recommended intravenous agents include fluoroquinolones, aminoglycosides (with or without ampicillin), extended-spectrum cephalosporins / penicillins, or carbapenems.

Analysis

Previous guidelines for the treatment of uncomplicated cystitis and pyelonephritis were published by the IDSA in 1999.⁴ The guidelines were updated based on the following factors:

• continued variability in prescribing practices;1-2
• increase in antimicrobial resistance among uropathogens;
• awareness of the unintended consequences of antimicrobial therapy, such as selection of drug-resistant organisms and colonization or infection with multi-drug resistant organisms; and
• study of newer agents and different durations of therapy.

Two important differences exist between the 1999 and 2010 guidelines:

• Nitrofurantoin has taken on more prominence in the 2010 guidelines for uncomplicated cystitis. The 1999 guidelines recommended trimethoprim-sulfamethoxazole as a first-line agent and mentioned nitrofurantoin and fosfomycin as potential alternative agents, but had few studies available to inform comparative efficacy or duration of therapy.
• For the outpatient treatment of mildly-ill patients with acute pyelonephritis, the 1999 guidelines recommended 14 days of therapy regardless of the agent used; in contrast, the 2010 guidelines recommend a five- to seven-day course for oral fluoroquinolones.

The American Congress of Obstetricians and Gynecologists, American Urological Association, Association of Medical Microbiology and Infectious Diseases-Canada, and the Society for Academic Emergency Medicine have endorsed the 2010 IDSA-ESCMID guidelines. The IDSA and ESCMID plan to evaluate the need for revisions to the 2010 guidelines based on an annual review of the current literature.

HM Takeaways

The 2010 IDSA-ESCMID guidelines are a resource available to hospitalists treating acute uncomplicated cystitis and pyelonephritis. As important differences exist between the target population and the hospitalist’s patient population, there are some key points to consider for clinicians treating cystitis or pyelonephritis in hospitalized patients.

Importantly, while nitrofurantoin is favored as a first-line antimicrobial agent for cystitis in the 2010 IDSA-ESCMID guidelines, it might be problematic in hospitalized patients for several reasons:

• it is not approved or recommended for the treatment of pyelonephritis;
• it is contraindicated in patients with creatinine clearance <60 ml/min; and
• it is generally not recommended for use in patients >65 years old because of the risk of renal impairment (Beers Criteria).⁵

Additionally, the treatment of acute cystitis in men requires special consideration. Notably, nitrofurantoin is not recommended in men because of poor prostatic tissue penetration, and although studies are limited, some sources recommend a longer treatment duration of at least 7 days.⁶ Finally, hospitalized patients commonly have other conditions, such as urological abnormalities, indwelling Foley catheters, recent urinary tract instrumentation, recent use of antibiotics, risk for multi-drug resistant organisms, potential interactions with other medications, and immunosuppression. The presence of any of these factors will influence the choice of empiric therapy and may warrant treatment for complicated cystitis or pyelonephritis, which are not addressed by these guidelines.

Drs. Tarvin and Sponsler are academic hospitalists at Vanderbilt University School of Medicine in Nashville, Tenn.

References

1. Huang ES, Stafford RS. National patterns in the treatment of urinary tract infections in women by ambulatory care physicians. Arch Intern Med. 2006;166:635-639.
2. Kahan NR, Chinitz DP, Kahan E. Longer than recommended empiric antibiotic treatment of urinary tract infection in women: an avoidable waste of money. J Clin Pharm Therap. 2004;29:59-63.
3. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Inf Dis. 2011;52(5):e103-20.
4. Warren JW, Abrutyn E, Hebel JR, Schaeffer AJ, Stamm WE. Guidelines for antimicrobial treatment of acute bacterial cystitis and acute pyelonephritis in women. Infectious Diseases Society of America. Clin Inf Dis. 1999;29(4):745-58.
5. Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a U.S. consensus panel of experts. Arch Intern Med. 2003;163(22):2716-2724.
6. Mehnert-Kay SA. Diagnosis and management of uncomplicated urinary tract infections. A Fam Phys. 2005;72(3):451-456.

Four hospitalists have joined Team Hospitalist, the only readerinvolvement group of its kind in HM. Each of the new members has experience in the practice of HM; many offer specialized backgrounds in pediatrics, academics, and group administration. The new members will serve two-year terms and act as special editorial consultants to the magazine.

Rajan Gurunathan, MD

Chief, section of hospital medicine, Division of General Medicine, associate attending, Department of Medicine, St. Luke’s-Roosevelt Hospital Center, New York, N.Y.

Nick Fitterman, MD, FACp, SFHM

Chief of staff and director of hospitalist services, Huntington Hospital, Huntington, N.Y., assistant professor of medicine, Hofstra University School of Medicine

Chithra R. Perumalswami, MD

Assistant professor of medicine, division of hospital medicine, section of palliative care, Northwestern University Feinberg School of Medicine, Chicago

Edward Ma, MD

Principal, The Hospitalist Consulting Group, LLC, Glen Mills, Pa., hospitalist, Chester County Hospital, West Chester, Pa.

Four hospitalists have joined Team Hospitalist, the only readerinvolvement group of its kind in HM. Each of the new members has experience in the practice of HM; many offer specialized backgrounds in pediatrics, academics, and group administration. The new members will serve two-year terms and act as special editorial consultants to the magazine.

Rajan Gurunathan, MD

Chief, section of hospital medicine, Division of General Medicine, associate attending, Department of Medicine, St. Luke’s-Roosevelt Hospital Center, New York, N.Y.

Nick Fitterman, MD, FACp, SFHM

Chief of staff and director of hospitalist services, Huntington Hospital, Huntington, N.Y., assistant professor of medicine, Hofstra University School of Medicine

Chithra R. Perumalswami, MD

Assistant professor of medicine, division of hospital medicine, section of palliative care, Northwestern University Feinberg School of Medicine, Chicago

Edward Ma, MD

Principal, The Hospitalist Consulting Group, LLC, Glen Mills, Pa., hospitalist, Chester County Hospital, West Chester, Pa.

Four hospitalists have joined Team Hospitalist, the only readerinvolvement group of its kind in HM. Each of the new members has experience in the practice of HM; many offer specialized backgrounds in pediatrics, academics, and group administration. The new members will serve two-year terms and act as special editorial consultants to the magazine.

Rajan Gurunathan, MD

Chief, section of hospital medicine, Division of General Medicine, associate attending, Department of Medicine, St. Luke’s-Roosevelt Hospital Center, New York, N.Y.

Nick Fitterman, MD, FACp, SFHM

Chief of staff and director of hospitalist services, Huntington Hospital, Huntington, N.Y., assistant professor of medicine, Hofstra University School of Medicine

Chithra R. Perumalswami, MD

Assistant professor of medicine, division of hospital medicine, section of palliative care, Northwestern University Feinberg School of Medicine, Chicago

Edward Ma, MD

Principal, The Hospitalist Consulting Group, LLC, Glen Mills, Pa., hospitalist, Chester County Hospital, West Chester, Pa.

In addition to the annual meeting, SHM and its partners bring hospitalists the very best in education, professional development, and networking in the form of in-person meetings.

July: Pediatric Hospital Medicine

Every year, hundreds of pediatric hospitalists come together to share their passion for caring for hospitalized children. This year, Pediatric Hospital Medicine 2012 will convene July 19-22 at the Northern Kentucky Convention Center, just outside Cincinnati. The meeting is co-sponsored by the Academic Pediatric Association, SHM, and the American Academy of Pediatrics.

For details and to register, visit www.hospitalmedicine.org/events.

October: Leadership Academy

SHM’s Leadership Academy continues to create the next generation of hospitalist leaders and sharpen the skills of existing leaders.

SHM will present its next industry-leading Leadership Academy Oct. 1-4 in Scottsdale, Ariz. The program will feature the popular “Foundations of Effective Leadership” course and the second-level “Advanced Leadership: Strategies and Tools for Personal Leadership Excellence” course.

Both courses build leadership skills for hospitalists, or, as more than one hospitalist has called the curriculum, “everything they don’t teach you in medical school.”

In the highly interactive, four-day “Foundations of Effective Leadership” course, hospitalists learn how to evaluate personal leadership strengths and weaknesses, create and execute a communication strategy for key team members, understand key hospital drivers, and examine how hospital metrics are derived.

The “Advanced Leadership: Strategies and Tools for Personal Leadership Excellence” program provides skills building for hospitalists who want to drive culture change through specific leadership behaviors and actions. It also delves deep into financial storytelling, effective professional negotiation activities with proven techniques, and more.

“Advanced Leadership” is a second-level course and is open only to hospitalists who have completed the “Foundations of Effective Leadership” course, or who have earned an advanced management degree, such as an MBA.

Both courses are required for the new Leadership Certification program, which gives hospitalists the ability to demonstrate their leadership skills through certification.

Hospitalists planning to take any Leadership Academy course should note that, starting in 2013, Leadership Academy courses will be offered only in the fall.

For details and registration, visit www.hospitalmedicine.org/leadership.

Anytime: Online Education

Hospitalists working to demonstrate their expertise and commitment to HM through the Focused Practice in Hospital Medicine designation can earn Maintenance of Certification (MOC) self-evaluation points and CME credit online at www.hospitalmedicine.org/mkm.

SHM’s Medical Knowledge Modules are online learning and self-evaluation tools that provide the user with industry-leading instruction on quality-improvement (QI) theory; project design; system processes; measurement; chance science; tools for implementation; epidemiology of patient safety; and error types, disclosure, prevention strategies, and theory.

Three Medical Knowledge Modules are available: Hospital QI and Patient Safety, Hospital QI and Patient Safety II, and Pediatric Hospital QI and Patient Safety. Each online module consists of 25 multiple-choice questions. If the correct answer is chosen, the module provides a rationale explaining why that answer was correct. When an incorrect answer is selected, users are encouraged to try again.

Each module will earn hospitalists 10 self-evaluation points for diplomates enrolled in ABIM’s MOC program and three AMA PRA Category 1 CME Credits.

SHM will continue to roll out other topics throughout 2012.

Brendon Shank is SHM associate vice president of communications.

In addition to the annual meeting, SHM and its partners bring hospitalists the very best in education, professional development, and networking in the form of in-person meetings.

July: Pediatric Hospital Medicine

Every year, hundreds of pediatric hospitalists come together to share their passion for caring for hospitalized children. This year, Pediatric Hospital Medicine 2012 will convene July 19-22 at the Northern Kentucky Convention Center, just outside Cincinnati. The meeting is co-sponsored by the Academic Pediatric Association, SHM, and the American Academy of Pediatrics.

For details and to register, visit www.hospitalmedicine.org/events.

October: Leadership Academy

SHM’s Leadership Academy continues to create the next generation of hospitalist leaders and sharpen the skills of existing leaders.

SHM will present its next industry-leading Leadership Academy Oct. 1-4 in Scottsdale, Ariz. The program will feature the popular “Foundations of Effective Leadership” course and the second-level “Advanced Leadership: Strategies and Tools for Personal Leadership Excellence” course.

Both courses build leadership skills for hospitalists, or, as more than one hospitalist has called the curriculum, “everything they don’t teach you in medical school.”

In the highly interactive, four-day “Foundations of Effective Leadership” course, hospitalists learn how to evaluate personal leadership strengths and weaknesses, create and execute a communication strategy for key team members, understand key hospital drivers, and examine how hospital metrics are derived.

The “Advanced Leadership: Strategies and Tools for Personal Leadership Excellence” program provides skills building for hospitalists who want to drive culture change through specific leadership behaviors and actions. It also delves deep into financial storytelling, effective professional negotiation activities with proven techniques, and more.

“Advanced Leadership” is a second-level course and is open only to hospitalists who have completed the “Foundations of Effective Leadership” course, or who have earned an advanced management degree, such as an MBA.

Both courses are required for the new Leadership Certification program, which gives hospitalists the ability to demonstrate their leadership skills through certification.

Hospitalists planning to take any Leadership Academy course should note that, starting in 2013, Leadership Academy courses will be offered only in the fall.

For details and registration, visit www.hospitalmedicine.org/leadership.

Anytime: Online Education

Hospitalists working to demonstrate their expertise and commitment to HM through the Focused Practice in Hospital Medicine designation can earn Maintenance of Certification (MOC) self-evaluation points and CME credit online at www.hospitalmedicine.org/mkm.

SHM’s Medical Knowledge Modules are online learning and self-evaluation tools that provide the user with industry-leading instruction on quality-improvement (QI) theory; project design; system processes; measurement; chance science; tools for implementation; epidemiology of patient safety; and error types, disclosure, prevention strategies, and theory.

Three Medical Knowledge Modules are available: Hospital QI and Patient Safety, Hospital QI and Patient Safety II, and Pediatric Hospital QI and Patient Safety. Each online module consists of 25 multiple-choice questions. If the correct answer is chosen, the module provides a rationale explaining why that answer was correct. When an incorrect answer is selected, users are encouraged to try again.

Each module will earn hospitalists 10 self-evaluation points for diplomates enrolled in ABIM’s MOC program and three AMA PRA Category 1 CME Credits.

SHM will continue to roll out other topics throughout 2012.

Brendon Shank is SHM associate vice president of communications.

In addition to the annual meeting, SHM and its partners bring hospitalists the very best in education, professional development, and networking in the form of in-person meetings.

July: Pediatric Hospital Medicine

Every year, hundreds of pediatric hospitalists come together to share their passion for caring for hospitalized children. This year, Pediatric Hospital Medicine 2012 will convene July 19-22 at the Northern Kentucky Convention Center, just outside Cincinnati. The meeting is co-sponsored by the Academic Pediatric Association, SHM, and the American Academy of Pediatrics.

For details and to register, visit www.hospitalmedicine.org/events.

October: Leadership Academy

SHM’s Leadership Academy continues to create the next generation of hospitalist leaders and sharpen the skills of existing leaders.

SHM will present its next industry-leading Leadership Academy Oct. 1-4 in Scottsdale, Ariz. The program will feature the popular “Foundations of Effective Leadership” course and the second-level “Advanced Leadership: Strategies and Tools for Personal Leadership Excellence” course.

Both courses build leadership skills for hospitalists, or, as more than one hospitalist has called the curriculum, “everything they don’t teach you in medical school.”

In the highly interactive, four-day “Foundations of Effective Leadership” course, hospitalists learn how to evaluate personal leadership strengths and weaknesses, create and execute a communication strategy for key team members, understand key hospital drivers, and examine how hospital metrics are derived.

The “Advanced Leadership: Strategies and Tools for Personal Leadership Excellence” program provides skills building for hospitalists who want to drive culture change through specific leadership behaviors and actions. It also delves deep into financial storytelling, effective professional negotiation activities with proven techniques, and more.

“Advanced Leadership” is a second-level course and is open only to hospitalists who have completed the “Foundations of Effective Leadership” course, or who have earned an advanced management degree, such as an MBA.

Both courses are required for the new Leadership Certification program, which gives hospitalists the ability to demonstrate their leadership skills through certification.

Hospitalists planning to take any Leadership Academy course should note that, starting in 2013, Leadership Academy courses will be offered only in the fall.

For details and registration, visit www.hospitalmedicine.org/leadership.

Anytime: Online Education

Hospitalists working to demonstrate their expertise and commitment to HM through the Focused Practice in Hospital Medicine designation can earn Maintenance of Certification (MOC) self-evaluation points and CME credit online at www.hospitalmedicine.org/mkm.

SHM’s Medical Knowledge Modules are online learning and self-evaluation tools that provide the user with industry-leading instruction on quality-improvement (QI) theory; project design; system processes; measurement; chance science; tools for implementation; epidemiology of patient safety; and error types, disclosure, prevention strategies, and theory.

Three Medical Knowledge Modules are available: Hospital QI and Patient Safety, Hospital QI and Patient Safety II, and Pediatric Hospital QI and Patient Safety. Each online module consists of 25 multiple-choice questions. If the correct answer is chosen, the module provides a rationale explaining why that answer was correct. When an incorrect answer is selected, users are encouraged to try again.

Each module will earn hospitalists 10 self-evaluation points for diplomates enrolled in ABIM’s MOC program and three AMA PRA Category 1 CME Credits.

SHM will continue to roll out other topics throughout 2012.

Brendon Shank is SHM associate vice president of communications.

Perhaps one of the most interesting concepts in the 2011 SHM/MGMA State of Hospital Medicine report is illustrated by the potentially confusing graph, at right, which is reproduced from the report. By taking a few minutes to fully understand what the graph portrays, users can gain valuable insights into the relationship between productivity and compensation.

Let’s say I’m a hospitalist and my annual work RVU (wRVU) productivity is in the bottom 25% (first quartile) of all of the hospitalists who responded to the survey. My total compensation is likely to be relatively low—a median of $188,800—but my compensation per unit of work is likely to be relatively high—a median of $73.85 per wRVU.

On the other hand, if I’m a hospitalist with productivity in the top 25% of all hospitalists (fourth quartile), my overall compensation will probably be much higher—a median of $260,283—but my average compensation per unit of work has probably gone down quite a bit (note the median of $40.82 per wRVU).

Why is it that my compensation has gone up, but not at the same rate as my productivity?

click for large version

Well, despite the increasing popularity of productivity incentives among HM groups in recent years, the majority of hospitalists still receive most of their pay in the form of a fixed salary. In fact, the survey, at right, found that the average hospitalist compensation package consists of about 80% fixed-base compensation, 16% productivity incentive, and 4% quality/performance incentive. Such compensation models give clear advantages to hospitalists with low productivity, and disadvantages to those with very high productivity.

Yes, many hospitalists can earn at least a bit more if they increase their productivity, but it’s often pennies on the dollar because neither their base salary nor their quality bonus components increase as their productivity goes up. Some of you might argue that compensation should rise in a straight line along with productivity, as it does in a practice with a 100% productivity-based compensation plan (some know this as the “eat what you treat” plan).

But what rises in a straight line can also fall in a straight line, and few hospitalists are comfortable with the risk of significant drops in income if their volume decreases for some reason.

Others might argue that it’s a good thing for compensation increases to taper off at high productivity levels, since this provides at least some reward for working harder but is less likely to incentivize people to work at unreasonable levels. And a few might argue that compensation per unit of work should actually increase at high productivity levels because once a hospitalist has covered their base salary and contribution to practice overhead, any additional revenue they bring into the practice is pure profit.

I have my opinions about these things, and I’m sure you do, too. But one of the things I like best about HM is the wide variety of practices out there. With so many hospitalist practices and so much variety, there’s a compensation model out there somewhere to suit everyone.

Perhaps one of the most interesting concepts in the 2011 SHM/MGMA State of Hospital Medicine report is illustrated by the potentially confusing graph, at right, which is reproduced from the report. By taking a few minutes to fully understand what the graph portrays, users can gain valuable insights into the relationship between productivity and compensation.

Let’s say I’m a hospitalist and my annual work RVU (wRVU) productivity is in the bottom 25% (first quartile) of all of the hospitalists who responded to the survey. My total compensation is likely to be relatively low—a median of $188,800—but my compensation per unit of work is likely to be relatively high—a median of $73.85 per wRVU.

On the other hand, if I’m a hospitalist with productivity in the top 25% of all hospitalists (fourth quartile), my overall compensation will probably be much higher—a median of $260,283—but my average compensation per unit of work has probably gone down quite a bit (note the median of $40.82 per wRVU).

Why is it that my compensation has gone up, but not at the same rate as my productivity?

click for large version

Well, despite the increasing popularity of productivity incentives among HM groups in recent years, the majority of hospitalists still receive most of their pay in the form of a fixed salary. In fact, the survey, at right, found that the average hospitalist compensation package consists of about 80% fixed-base compensation, 16% productivity incentive, and 4% quality/performance incentive. Such compensation models give clear advantages to hospitalists with low productivity, and disadvantages to those with very high productivity.

Yes, many hospitalists can earn at least a bit more if they increase their productivity, but it’s often pennies on the dollar because neither their base salary nor their quality bonus components increase as their productivity goes up. Some of you might argue that compensation should rise in a straight line along with productivity, as it does in a practice with a 100% productivity-based compensation plan (some know this as the “eat what you treat” plan).

But what rises in a straight line can also fall in a straight line, and few hospitalists are comfortable with the risk of significant drops in income if their volume decreases for some reason.

Others might argue that it’s a good thing for compensation increases to taper off at high productivity levels, since this provides at least some reward for working harder but is less likely to incentivize people to work at unreasonable levels. And a few might argue that compensation per unit of work should actually increase at high productivity levels because once a hospitalist has covered their base salary and contribution to practice overhead, any additional revenue they bring into the practice is pure profit.

I have my opinions about these things, and I’m sure you do, too. But one of the things I like best about HM is the wide variety of practices out there. With so many hospitalist practices and so much variety, there’s a compensation model out there somewhere to suit everyone.

Perhaps one of the most interesting concepts in the 2011 SHM/MGMA State of Hospital Medicine report is illustrated by the potentially confusing graph, at right, which is reproduced from the report. By taking a few minutes to fully understand what the graph portrays, users can gain valuable insights into the relationship between productivity and compensation.

Let’s say I’m a hospitalist and my annual work RVU (wRVU) productivity is in the bottom 25% (first quartile) of all of the hospitalists who responded to the survey. My total compensation is likely to be relatively low—a median of $188,800—but my compensation per unit of work is likely to be relatively high—a median of $73.85 per wRVU.

On the other hand, if I’m a hospitalist with productivity in the top 25% of all hospitalists (fourth quartile), my overall compensation will probably be much higher—a median of $260,283—but my average compensation per unit of work has probably gone down quite a bit (note the median of $40.82 per wRVU).

Why is it that my compensation has gone up, but not at the same rate as my productivity?

click for large version

Well, despite the increasing popularity of productivity incentives among HM groups in recent years, the majority of hospitalists still receive most of their pay in the form of a fixed salary. In fact, the survey, at right, found that the average hospitalist compensation package consists of about 80% fixed-base compensation, 16% productivity incentive, and 4% quality/performance incentive. Such compensation models give clear advantages to hospitalists with low productivity, and disadvantages to those with very high productivity.

Yes, many hospitalists can earn at least a bit more if they increase their productivity, but it’s often pennies on the dollar because neither their base salary nor their quality bonus components increase as their productivity goes up. Some of you might argue that compensation should rise in a straight line along with productivity, as it does in a practice with a 100% productivity-based compensation plan (some know this as the “eat what you treat” plan).

But what rises in a straight line can also fall in a straight line, and few hospitalists are comfortable with the risk of significant drops in income if their volume decreases for some reason.

Others might argue that it’s a good thing for compensation increases to taper off at high productivity levels, since this provides at least some reward for working harder but is less likely to incentivize people to work at unreasonable levels. And a few might argue that compensation per unit of work should actually increase at high productivity levels because once a hospitalist has covered their base salary and contribution to practice overhead, any additional revenue they bring into the practice is pure profit.

I have my opinions about these things, and I’m sure you do, too. But one of the things I like best about HM is the wide variety of practices out there. With so many hospitalist practices and so much variety, there’s a compensation model out there somewhere to suit everyone.

Meadowview Regional Medical Center in Maysville, Ky., recently added a hospitalist program as part of its renovation campaign. Jeff Dickerson, MD, Ignacio Calvo, MD, and nurse practitioner Abe Keating are heading up the new hospitalist team.

Eric McFarling, MD, a hospitalist at St. Cloud Hospital in St. Cloud, Minn., received the Physician of Excellence Award from employees and peers. The award recognizes commitment to patient satisfaction and teamwork.

Emily Hebert, MD, an internal-medicine hospitalist at Baylor University Medical Center in Waco, Texas, was awarded the 2011 Texas Medical Association’s Anson Jones, MD, Award in the Physician Excellence in Reporting category for her work as medical expert for the local ABC affiliate. She recently joined the staff at The Cooper Clinic in Dallas as a preventive- medicine physician, specializing in internal medicine and pediatrics.

Business Moves

IPC: the Hospitalist Co. has signed agreements to acquire Inpatient Clinical Solutions Inc. (ICS), an acute-care practice headquartered in Coral Springs, Fla., and the hospitalist practice of Lionel J. Gatien, DO, PA, based in Jacksonville, Fla. IPC expects to add approximately 116,000 patient visits on an annual basis from these acquisitions.

Glendale, Calif.-based Apollo Medical Holdings Inc., a hospitalist-, critical-care and multi-disciplinary care-management service, has appointed Edward “Ted” Schreck chairman of the board. Schreck is a senior healthcare executive with 37 years of experience in both the private and public healthcare sectors.

Carlisle (Pa.) Regional Medical Center has added a 12-member hospitalist team to its list of medical departments. The team will be known as Hospitalists of Central Pennsylvania. Michael Hilden, MD, will serve as group director.

—Alexandra Schultz

Meadowview Regional Medical Center in Maysville, Ky., recently added a hospitalist program as part of its renovation campaign. Jeff Dickerson, MD, Ignacio Calvo, MD, and nurse practitioner Abe Keating are heading up the new hospitalist team.

Eric McFarling, MD, a hospitalist at St. Cloud Hospital in St. Cloud, Minn., received the Physician of Excellence Award from employees and peers. The award recognizes commitment to patient satisfaction and teamwork.

Emily Hebert, MD, an internal-medicine hospitalist at Baylor University Medical Center in Waco, Texas, was awarded the 2011 Texas Medical Association’s Anson Jones, MD, Award in the Physician Excellence in Reporting category for her work as medical expert for the local ABC affiliate. She recently joined the staff at The Cooper Clinic in Dallas as a preventive- medicine physician, specializing in internal medicine and pediatrics.

Business Moves

IPC: the Hospitalist Co. has signed agreements to acquire Inpatient Clinical Solutions Inc. (ICS), an acute-care practice headquartered in Coral Springs, Fla., and the hospitalist practice of Lionel J. Gatien, DO, PA, based in Jacksonville, Fla. IPC expects to add approximately 116,000 patient visits on an annual basis from these acquisitions.

Glendale, Calif.-based Apollo Medical Holdings Inc., a hospitalist-, critical-care and multi-disciplinary care-management service, has appointed Edward “Ted” Schreck chairman of the board. Schreck is a senior healthcare executive with 37 years of experience in both the private and public healthcare sectors.

Carlisle (Pa.) Regional Medical Center has added a 12-member hospitalist team to its list of medical departments. The team will be known as Hospitalists of Central Pennsylvania. Michael Hilden, MD, will serve as group director.

—Alexandra Schultz

Meadowview Regional Medical Center in Maysville, Ky., recently added a hospitalist program as part of its renovation campaign. Jeff Dickerson, MD, Ignacio Calvo, MD, and nurse practitioner Abe Keating are heading up the new hospitalist team.

Eric McFarling, MD, a hospitalist at St. Cloud Hospital in St. Cloud, Minn., received the Physician of Excellence Award from employees and peers. The award recognizes commitment to patient satisfaction and teamwork.

Emily Hebert, MD, an internal-medicine hospitalist at Baylor University Medical Center in Waco, Texas, was awarded the 2011 Texas Medical Association’s Anson Jones, MD, Award in the Physician Excellence in Reporting category for her work as medical expert for the local ABC affiliate. She recently joined the staff at The Cooper Clinic in Dallas as a preventive- medicine physician, specializing in internal medicine and pediatrics.

Business Moves

IPC: the Hospitalist Co. has signed agreements to acquire Inpatient Clinical Solutions Inc. (ICS), an acute-care practice headquartered in Coral Springs, Fla., and the hospitalist practice of Lionel J. Gatien, DO, PA, based in Jacksonville, Fla. IPC expects to add approximately 116,000 patient visits on an annual basis from these acquisitions.

Glendale, Calif.-based Apollo Medical Holdings Inc., a hospitalist-, critical-care and multi-disciplinary care-management service, has appointed Edward “Ted” Schreck chairman of the board. Schreck is a senior healthcare executive with 37 years of experience in both the private and public healthcare sectors.

Carlisle (Pa.) Regional Medical Center has added a 12-member hospitalist team to its list of medical departments. The team will be known as Hospitalists of Central Pennsylvania. Michael Hilden, MD, will serve as group director.

—Alexandra Schultz

On March 7, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule: Medicare and Medicaid Programs; Electronic Health Record Incentive Program—Stage 2. This rule is more commonly known as “Stage 2 of meaningful use.” At more than 130 pages, the rule builds upon Stage 1 of the program mainly by increasing measurement thresholds and requiring higher levels of system functionality.

Although there are no major surprises within the proposed rule, there is always one very basic yet very important question that surfaces when meaningful use makes headlines: Are hospitalists eligible for health information technology (HIT) incentives and thus subject to the meaningful use requirements?

“No” is the short answer to this question. Although physicians, including hospitalists, are considered eligible professionals (EPs) under the HIT incentive program, a subset of EPs are defined as hospital-based EPs and, therefore, are not subject to the program’s requirements. CMS defines a hospital-based eligible professional as an EP who furnishes 90% or more of their covered professional services in either the inpatient division or ED of a hospital.

While some may call this an exemption for hospitalists, it is not that definitive. Hospitalists are still “eligible,” and the determination is not made by specialty, but by pattern of practice. This means that hospitalists could find themselves on the hook for future penalties if their practice patterns expand beyond CMS’ 90% threshold.

An example of this would be a hospitalist who spends time doing rounds at a nursing home. Today, this might constitute only a small percentage of a hospitalist’s practice, but with an increasingly aging population, it is not inconceivable that this small percentage could exceed 10% within five or 10 years.

With this in mind, and a similar scenario also present in the Electronic Prescribing Incentive Program (eRx), SHM has consistently pointed out the issue to CMS and is working to find an acceptable solution.

Although hospitalists are not currently subject to physician meaningful-use requirements, the program has another category of eligibility that will certainly affect hospitalists: the eligible hospital, or EH. Many hospitalists are directly involved with HIT implementation efforts at their institutions or are indirectly working with these systems as they are implemented and expanded in hospitals across the country.

Given the 90% eligibility threshold and the role of HIT in hospitals, it is important for hospitalists to stay current and informed on meaningful use and HIT policy. Involvement with one of SHM’s HIT related committees is a clear way to stay informed in this ever-evolving area, and SHM’s efforts can be reviewed on the Advocacy page of SHM’s website: www.hospitalmedicine.org/advocacy.

For the most up-to-date information on what is being done at the federal level, the Office of the National Coordinator (ONC) has a wealth of information available at www.healthit.gov/.

SHM will continue to monitor and analyze developments and changes to EHR policy, but it also looks to you, its members, for experience and insight.

On March 7, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule: Medicare and Medicaid Programs; Electronic Health Record Incentive Program—Stage 2. This rule is more commonly known as “Stage 2 of meaningful use.” At more than 130 pages, the rule builds upon Stage 1 of the program mainly by increasing measurement thresholds and requiring higher levels of system functionality.

Although there are no major surprises within the proposed rule, there is always one very basic yet very important question that surfaces when meaningful use makes headlines: Are hospitalists eligible for health information technology (HIT) incentives and thus subject to the meaningful use requirements?

“No” is the short answer to this question. Although physicians, including hospitalists, are considered eligible professionals (EPs) under the HIT incentive program, a subset of EPs are defined as hospital-based EPs and, therefore, are not subject to the program’s requirements. CMS defines a hospital-based eligible professional as an EP who furnishes 90% or more of their covered professional services in either the inpatient division or ED of a hospital.

While some may call this an exemption for hospitalists, it is not that definitive. Hospitalists are still “eligible,” and the determination is not made by specialty, but by pattern of practice. This means that hospitalists could find themselves on the hook for future penalties if their practice patterns expand beyond CMS’ 90% threshold.

An example of this would be a hospitalist who spends time doing rounds at a nursing home. Today, this might constitute only a small percentage of a hospitalist’s practice, but with an increasingly aging population, it is not inconceivable that this small percentage could exceed 10% within five or 10 years.

With this in mind, and a similar scenario also present in the Electronic Prescribing Incentive Program (eRx), SHM has consistently pointed out the issue to CMS and is working to find an acceptable solution.

Although hospitalists are not currently subject to physician meaningful-use requirements, the program has another category of eligibility that will certainly affect hospitalists: the eligible hospital, or EH. Many hospitalists are directly involved with HIT implementation efforts at their institutions or are indirectly working with these systems as they are implemented and expanded in hospitals across the country.

Given the 90% eligibility threshold and the role of HIT in hospitals, it is important for hospitalists to stay current and informed on meaningful use and HIT policy. Involvement with one of SHM’s HIT related committees is a clear way to stay informed in this ever-evolving area, and SHM’s efforts can be reviewed on the Advocacy page of SHM’s website: www.hospitalmedicine.org/advocacy.

For the most up-to-date information on what is being done at the federal level, the Office of the National Coordinator (ONC) has a wealth of information available at www.healthit.gov/.

SHM will continue to monitor and analyze developments and changes to EHR policy, but it also looks to you, its members, for experience and insight.

On March 7, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule: Medicare and Medicaid Programs; Electronic Health Record Incentive Program—Stage 2. This rule is more commonly known as “Stage 2 of meaningful use.” At more than 130 pages, the rule builds upon Stage 1 of the program mainly by increasing measurement thresholds and requiring higher levels of system functionality.

Although there are no major surprises within the proposed rule, there is always one very basic yet very important question that surfaces when meaningful use makes headlines: Are hospitalists eligible for health information technology (HIT) incentives and thus subject to the meaningful use requirements?

“No” is the short answer to this question. Although physicians, including hospitalists, are considered eligible professionals (EPs) under the HIT incentive program, a subset of EPs are defined as hospital-based EPs and, therefore, are not subject to the program’s requirements. CMS defines a hospital-based eligible professional as an EP who furnishes 90% or more of their covered professional services in either the inpatient division or ED of a hospital.

While some may call this an exemption for hospitalists, it is not that definitive. Hospitalists are still “eligible,” and the determination is not made by specialty, but by pattern of practice. This means that hospitalists could find themselves on the hook for future penalties if their practice patterns expand beyond CMS’ 90% threshold.

An example of this would be a hospitalist who spends time doing rounds at a nursing home. Today, this might constitute only a small percentage of a hospitalist’s practice, but with an increasingly aging population, it is not inconceivable that this small percentage could exceed 10% within five or 10 years.

With this in mind, and a similar scenario also present in the Electronic Prescribing Incentive Program (eRx), SHM has consistently pointed out the issue to CMS and is working to find an acceptable solution.

Although hospitalists are not currently subject to physician meaningful-use requirements, the program has another category of eligibility that will certainly affect hospitalists: the eligible hospital, or EH. Many hospitalists are directly involved with HIT implementation efforts at their institutions or are indirectly working with these systems as they are implemented and expanded in hospitals across the country.

Given the 90% eligibility threshold and the role of HIT in hospitals, it is important for hospitalists to stay current and informed on meaningful use and HIT policy. Involvement with one of SHM’s HIT related committees is a clear way to stay informed in this ever-evolving area, and SHM’s efforts can be reviewed on the Advocacy page of SHM’s website: www.hospitalmedicine.org/advocacy.

For the most up-to-date information on what is being done at the federal level, the Office of the National Coordinator (ONC) has a wealth of information available at www.healthit.gov/.

SHM will continue to monitor and analyze developments and changes to EHR policy, but it also looks to you, its members, for experience and insight.