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The Case

A 52-year-old man presents with abdominal pain. His temperature is 100.8°F, his blood pressure is 170/90 mm/Hg, and his pulse is 110 beats per minute. On exam, he has 2+ lower extremity edema, periorbital edema, and left-sided flank tenderness. His BUN is 42 mg/dL, his creatinine is 2.5 mg/dL, and his albumin is 1.4 g/dL. Urinalysis shows 2+ protein, large blood, and red blood cells (RBCs). What are the next steps in his diagnosis?

Overview

Glomerular diseases involve a wide spectrum of disease processes. They can result from an acute illness, such as an upper respiratory infection that self-resolves, or from chronic disease states, such as HIV. In some instances, such illnesses as systemic lupus erythematosus (SLE) can cause rapidly progressive renal failure, requiring prompt intervention. While glomerular diseases can be daunting, it is essential for hospitalists to be familiar with fundamental concepts and key features unique to each syndrome.

The approach to glomerulonephritis (GN) can be simplified by summarizing various types into the two broad categories of nephrotic and nephritic syndromes, and identifying the key clinical findings (see Table 1, p. below).

The major subtypes of nephrotic syndrome are minimal change disease (MCD), focal segmental glomerulosclerosis (FSGS), membranous nephropathy (MN), and membranoproliferative glomerulonephritis (MPGN). The clinical manifestations of nephrotic syndrome are edema, hyperlipidemia, lipiduria, and hypoalbuminemia.1 The urinalysis is significant for >3.5 g/day of proteinuria showing fatty casts or oval fat bodies.² The loss of other proteins, such as anti-thrombin III, may put patients at higher risk for developing venous thromboses.¹

The major subtypes of nephritic syndrome are post-streptococcal glomerulonephritis (PSGS), IgA nephropathy, Henoch-Schonlein Purpura (HSP), and rapidly progressive GN (RPGN types I, II, and III). The clinical manifestations of nephritic syndrome are hypertension (HTN) and hematuria.¹ Nephritic syndromes may present with more rapidly progressive renal failure when compared with nephrotic syndrome.¹ The urinalysis is significant for hematuria with RBC casts, and variable levels of proteinuria (typically, less than 3.5 g/day is seen in nephritic syndrome).¹

Review of the Data

Nephrotic Syndromes

Minimal change disease. MCD is more common in children than adults, and only accounts for 10% to 15% of glomerular disease cases in adults.³ It is associated with Hodgkin’s lymphoma, NSAID use, and allergic conditions. There usually is an absence of hypertension (HTN). There are no glomerular basement membrane abnormalities seen on light microscopy. Electron microscopy shows effacement of podocytes. On urinalysis, oval fat bodies are seen, which are characteristic of heavy proteinuria. Complement levels are normal. Steroids are first-line treatment, but in adults with relapses or steroid resistance, immunosuppressive agents have also been used.²

Focal segment glomerlosclerosis.

FSGS is the most common primary glomerular disorder in the United States and is the most common cause of nephrotic syndrome among blacks.^4,5 It is associated with HIV (collapsing variant), parvovirus B19, heroin use, sickle-cell disease, obesity, chronic vesicoureteral reflux, and HTN.^4,6 Sclerosis of segmental glomeruli is seen on light microscopy.

Electron microscopy shows effacement of podocytes. Complement levels are normal. Treatment of primary idiopathic FSGS includes use of renin-angiotensin inhibitors and steroids.⁴ Immunosuppressives are reserved for relapses. Treatment of secondary FSGS involves identifying the underlying cause.

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Membranous nephropathy. MN is twice as common in males as in females and is the most common cause of adult-onset idiopathic nephrotic syndrome, with the average presentation in the fifth or sixth decade of life.^7,8 Aside from its idiopathic form, up to 25% of MN cases have an underlying disease process, such as solid organ tumors or hepatitis B.^7,9 While nephrotic syndrome overall can increase the risk of thromboembolic complications, MN is the most common nephrotic disorder predisposing the development of renal vein thrombosis.⁷ Diffuse capillary wall thickening is seen on light microscopy, and electron microscopy shows sub-epithelial immune deposits. Complement levels are normal. Steroids and immunosuppressive agents are used for treatment.¹⁰

Membranoproliferative glomerulonephritis. MPGN is a nephrotic syndrome that is more common in children and young adults and can present with features of nephritic syndrome.^1,11 It is associated with hepatitis C, SLE, and cryoglobulinemia.¹¹ Light microscopy shows mesangial and endocapillary proliferation, as well as glomerular basement membrane thickening and splitting (“tram track” appearance). Electron microscopy shows subendothelial and dense deposits. It presents with reduced complement levels (C3 and C4).¹¹ Treatment depends on the associated disease.

Nephritic Syndromes

Post-streptococcal glomerulonephritis. PSGN is seen in children and young adults and is associated with skin (impetigo) and throat infections (pharyngitis).¹² Hematuria usually presents two to three weeks after a streptococcal infection. The urine is classically dark and smoky-colored. Levels of C3 and CH50 are low, but C4 levels are normal.1 In addition, there are positive antibody titers for ASO and anti-DNase. Light microscopy shows hypercellularity of glomeruli. Electron microscopy shows dome-shaped sub-endothelial deposits. Treatment is usually supportive.

click for large version

click for large version

IgA nephropathy. IgA nephropathy is the most common form of glomerular disease worldwide and the most common form of glomerular-related microscopic hematuria in all age groups.^2,13 It occurs in all ages but more frequently in males.¹⁴ It occurs during or immediately after an upper respiratory infection. Light microscopy shows mesangial cell proliferation and crescentic GN. Electron microscopy shows immune deposits in the mesangium. Complement levels are normal. There has been no proven therapy, but ACE inhibitors (ACE-Is), angiotensin receptor blockers (ARBs), fish oil, steroids, and tonsillectomy have been used with some success.¹⁴ The clinical course of IgA nephropathy can be highly variable, with the potential for a benign course to rapidly progressive renal failure, with 15% to 40% of patients developing end-stage renal disease.¹⁴

Henoch-Schonlein purpura. HSP affects children more than adults and is the systemic form of IgA nephropathy.14 Most cases are idiopathic. Clinical

manifestations include: HTN; purpuric palpable rash on buttocks, ankles, and legs; bloody diarrhea with abdominal cramps; and pain in wrist, ankle, and knee joints.¹⁵ Light microscopy shows mesangial cell proliferation. Immune deposits in the mesangium are seen on electron microscopy. Complement levels are normal. Treatment is supportive.

Rapidly progressive glomerulonephritis types I, II, and III. RPGN represents a wide variety of disease states in which rapid progression to renal failure is seen within days to weeks.¹⁶ They are categorized into three sub-categories: I, II, and III.

Type I is an anti-GBM disease, an example being Goodpasture’s syndrome. This condition presents with hemoptysis, pulmonary infiltrates, and hematuria with RBC casts. Anti-GBM antibodies are classically found.¹ Complement levels are normal and a linear immunofluorescence pattern is seen. Treatment is steroids, immunosuppressive agents, and plasmapheresis.¹⁷

Type II is an immune complex deposition disease, such as HSP, SLE, or post-streptococcal GN, in which granular complex deposits are seen. Treatment is directed toward treating the underlying cause.

Type III is pauci-immune (no immune deposits), showing necrotizing crescentic GN on biopsy, and is associated with a positive ANCA.^1,18 They are associated with systemic small-vessel vasculitis, such as granulomatosis with polyangiitis (formerly known as Wegener’s granulomatosis), microscopic polyangiitis, and Churg-Strauss syndrome, or can be limited to renal involvement.^1,18 Complement levels are normal. Treatment is steroids and immunosuppressive agents, such as cyclophosphamide.

A summary of the findings found in the glomerulonephritides and how complement levels are affected are found in Table 2 and Table 3, respectively.

Secondary Causes of Nephrotic Diseases

Diabetic nephropathy. Diabetic nephropathy is the single most common cause of progressive renal failure in the United States.³ Up to 50% of patients with diabetes present with diabetic nephropathy.¹⁹ Current recommendations are to screen yearly for microalbuminuria at the time of diagnosis.³ Treatment involves use of ACE-Is or ARBs to reduce proteinuria and slow the progression of renal disease.

HIV-associated nephropathy. HIV-associated nephropathy commonly presents as the collapsing variant of FSGS. However, it can present as other forms of glomerulopathy, such as MPGN or IgA nephropathy, as well as an immune complex GN with “lupus-like” features without evidence of SLE.^19,20 Therefore, HIV nephropathy has now been categorized as a separate entity.³ ACE-Is, HAART therapy, and corticosteroids are the mainstays of treatment.

Amyloidosis. Renal involvement is seen in both primary (AL) and secondary (AA) amyloidosis. Eighty percent of patients with AL have renal disease, and 25% of these patients have nephrotic syndrome.¹⁶ Diagnosis is made with Congo Red stain, which shows fibrillary amyloid deposits within the mesangium and capillary walls. Treatment is directed at the underlying process.

Systemic lupus erythematosus. SLE is divided into six classes (I-VI) based on the involvement and severity of renal disease, and steroids and immunosuppressive agents are used for treatment, also based on the severity of the disease.²¹

Back to the Case

Our patient presented to the hospital with abdominal pain, low-grade fever, HTN, edema, hypoalbuminemia, and new-onset renal failure with gross hematuria and proteinuria. The presence of proteinuria and hypoalbuminemia, combined with peripheral and periorbital edema, suggests glomerular loss of albumin, such as in nephrotic syndrome. His renal failure in the setting of the sudden development of gross hematuria with flank pain is concerning for a renal vein thrombosis, and an abdominal magnetic resonance venography did in fact visualize a renal vein thrombosis.

He was admitted to the hospital and was started on therapeutic intravenous heparin, and bridged to warfarin. Subsequent renal biopsy confirmed the findings of membranous nephropathy, which was suspected due to his renal vein thrombosis. Therapy was initiated with corticosteroids after the biopsy, and he responded well. Because of his risk factors for further thromboembolic events, lifelong anticoagulation therapy was recommended.

Bottom Line

For patients with glomerular disease, differentiating between nephrotic and nephritic syndromes and understanding key clinical and laboratory differences can lead to easier identification and treatment.

Drs. Khan and Smith are assistant professors of medicine, and Dr. Ansari is associate division director, in the Division of Hospital Medicine at Loyola University Medical Center, Maywood, Ill.

References

1. Donegio RGB, Salant DJ. Nephrology: Glomerular Diseases. In: ACP Medicine. Dale D, Federman D, eds. Available at: http://www.acpmedicine.com/acpmedicine/institutional/instHtmlReader.action?readerFlag=chapt&chapId=part10_ch05. Accessed Feb. 15, 2012.
2. Orth SR, Ritz E. The nephrotic syndrome. N Engl J Med. 1998;338:1202-1211.
3. Lewis JB, Neilson EG. Chapter 283. Glomerular Diseases. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine. 18th ed. New York: McGraw-Hill; 2012.
4. D’Agati VD, Kaskel FJ, Falk RJ. Focal segmental glomerulosclerosis. N Engl J Med. 2011;365:2398-23411.
5. Kitiyakara C, Eggers P, Kopp JB. Twenty-one-year trend in ESRD due to focal segmental glomerulosclerosis in the United States. Am J Kidney Dis. 2004;44:815-825.
6. Balow JE. Nephropathy in the context of HIV infection. Kidney Int. 2005;67:1632-1633.
7. Glassock RJ. Diagnosis and natural course of membranous nephropathy. Semin Nephrol. 2003;23:324-332.
8. Nickolas TL, Radhakrishnan J, Appel GB. Hyperlipidemia and thrombotic complications in patients with membranous nephropathy. Semin Nephrol. 2003;23:406-411.
9. Burstein DM, Korbet SM, Schwartz MM. Membranous glomerulonephritis and malignancy. Am J Kidney Dis. 1993;22:5-10.
10. Hofstra JM, Wetzels JF. Management of patients with membranous nephropathy. Nephrol Dial Transplant. 2012;27:6-9.
11. Alchi B, Jayne D. Membranoproliferative glomerulonephritis. Pediatr Nephrol. 2010;25:1409-1418.
12. Eison TM, Ault BH, Jones DP, Chesney RW, Wyatt RJ. Post-streptococcal acute glomerulonephritis in children: clinical features and pathogenesis. Pediatr Nephrol. 2011;26:165-180.
13. Cohen RA, Brown RS. Clinical practice. Microscopic hematuria. N Engl J Med. 2003;348:2330-2338.
14. Donadio JV, Grande JP. IgA nephropathy. N Engl J Med. 2002;347:738-748.
15. McCarthy HJ, Tizard EJ. Clinical practice: Diagnosis and management of henoch-schonlein purpura. Eur J Pediatr. 2010169:643-650.
16. Appel GB, Radhakrishnan J. Cecil Medicine: Volume 1: Chapter 123: Glomerular Disorders and Nephrotic Syndromes. MD Consult Preview website. Available at: http://www.mdconsult.com/books/page.do?eid=4-u1.0-B978-1-4377-1604-7..00123-8&isbn=978-1-4377-1604-7&uniqId=313771243-2#4-u1.0-B978-1-4377-1604-7..00123-8. Accessed Feb. 16, 2012.
17. Walters G, Willis NS, Craig JC. Interventions for renal vasculitis in adults. Cochrane Database Syst Rev. 2008;(3)(3):CD003232.
18. Jennette JC. Rapidly progressive crescentic glomerulonephritis. Kidney Int. 2003;63:1164-1177.
19. Falk, RJ: Medical Knowledge Self Assessment Program 14. Nephrology: 2006.
20. Haas M, Kaul S, Eustace JA. HIV-associated immune complex glomerulonephritis with “lupus-like” features: a clinicopathologic study of 14 cases. Kidney Int. 2005;67:1381.
21. Dooley MA, Hogan S, Jennette C, Falk R. Cyclophosphamide therapy for lupus nephritis: poor renal survival in black americans. glomerular disease collaborative network. Kidney Int. 1997;51:1188-1195.

click for large version

The Case

A 52-year-old man presents with abdominal pain. His temperature is 100.8°F, his blood pressure is 170/90 mm/Hg, and his pulse is 110 beats per minute. On exam, he has 2+ lower extremity edema, periorbital edema, and left-sided flank tenderness. His BUN is 42 mg/dL, his creatinine is 2.5 mg/dL, and his albumin is 1.4 g/dL. Urinalysis shows 2+ protein, large blood, and red blood cells (RBCs). What are the next steps in his diagnosis?

Overview

Glomerular diseases involve a wide spectrum of disease processes. They can result from an acute illness, such as an upper respiratory infection that self-resolves, or from chronic disease states, such as HIV. In some instances, such illnesses as systemic lupus erythematosus (SLE) can cause rapidly progressive renal failure, requiring prompt intervention. While glomerular diseases can be daunting, it is essential for hospitalists to be familiar with fundamental concepts and key features unique to each syndrome.

The approach to glomerulonephritis (GN) can be simplified by summarizing various types into the two broad categories of nephrotic and nephritic syndromes, and identifying the key clinical findings (see Table 1, p. below).

The major subtypes of nephrotic syndrome are minimal change disease (MCD), focal segmental glomerulosclerosis (FSGS), membranous nephropathy (MN), and membranoproliferative glomerulonephritis (MPGN). The clinical manifestations of nephrotic syndrome are edema, hyperlipidemia, lipiduria, and hypoalbuminemia.1 The urinalysis is significant for >3.5 g/day of proteinuria showing fatty casts or oval fat bodies.² The loss of other proteins, such as anti-thrombin III, may put patients at higher risk for developing venous thromboses.¹

The major subtypes of nephritic syndrome are post-streptococcal glomerulonephritis (PSGS), IgA nephropathy, Henoch-Schonlein Purpura (HSP), and rapidly progressive GN (RPGN types I, II, and III). The clinical manifestations of nephritic syndrome are hypertension (HTN) and hematuria.¹ Nephritic syndromes may present with more rapidly progressive renal failure when compared with nephrotic syndrome.¹ The urinalysis is significant for hematuria with RBC casts, and variable levels of proteinuria (typically, less than 3.5 g/day is seen in nephritic syndrome).¹

Review of the Data

Nephrotic Syndromes

Minimal change disease. MCD is more common in children than adults, and only accounts for 10% to 15% of glomerular disease cases in adults.³ It is associated with Hodgkin’s lymphoma, NSAID use, and allergic conditions. There usually is an absence of hypertension (HTN). There are no glomerular basement membrane abnormalities seen on light microscopy. Electron microscopy shows effacement of podocytes. On urinalysis, oval fat bodies are seen, which are characteristic of heavy proteinuria. Complement levels are normal. Steroids are first-line treatment, but in adults with relapses or steroid resistance, immunosuppressive agents have also been used.²

Focal segment glomerlosclerosis.

FSGS is the most common primary glomerular disorder in the United States and is the most common cause of nephrotic syndrome among blacks.^4,5 It is associated with HIV (collapsing variant), parvovirus B19, heroin use, sickle-cell disease, obesity, chronic vesicoureteral reflux, and HTN.^4,6 Sclerosis of segmental glomeruli is seen on light microscopy.

Electron microscopy shows effacement of podocytes. Complement levels are normal. Treatment of primary idiopathic FSGS includes use of renin-angiotensin inhibitors and steroids.⁴ Immunosuppressives are reserved for relapses. Treatment of secondary FSGS involves identifying the underlying cause.

click for large version

Membranous nephropathy. MN is twice as common in males as in females and is the most common cause of adult-onset idiopathic nephrotic syndrome, with the average presentation in the fifth or sixth decade of life.^7,8 Aside from its idiopathic form, up to 25% of MN cases have an underlying disease process, such as solid organ tumors or hepatitis B.^7,9 While nephrotic syndrome overall can increase the risk of thromboembolic complications, MN is the most common nephrotic disorder predisposing the development of renal vein thrombosis.⁷ Diffuse capillary wall thickening is seen on light microscopy, and electron microscopy shows sub-epithelial immune deposits. Complement levels are normal. Steroids and immunosuppressive agents are used for treatment.¹⁰

Membranoproliferative glomerulonephritis. MPGN is a nephrotic syndrome that is more common in children and young adults and can present with features of nephritic syndrome.^1,11 It is associated with hepatitis C, SLE, and cryoglobulinemia.¹¹ Light microscopy shows mesangial and endocapillary proliferation, as well as glomerular basement membrane thickening and splitting (“tram track” appearance). Electron microscopy shows subendothelial and dense deposits. It presents with reduced complement levels (C3 and C4).¹¹ Treatment depends on the associated disease.

Nephritic Syndromes

Post-streptococcal glomerulonephritis. PSGN is seen in children and young adults and is associated with skin (impetigo) and throat infections (pharyngitis).¹² Hematuria usually presents two to three weeks after a streptococcal infection. The urine is classically dark and smoky-colored. Levels of C3 and CH50 are low, but C4 levels are normal.1 In addition, there are positive antibody titers for ASO and anti-DNase. Light microscopy shows hypercellularity of glomeruli. Electron microscopy shows dome-shaped sub-endothelial deposits. Treatment is usually supportive.

click for large version

click for large version

IgA nephropathy. IgA nephropathy is the most common form of glomerular disease worldwide and the most common form of glomerular-related microscopic hematuria in all age groups.^2,13 It occurs in all ages but more frequently in males.¹⁴ It occurs during or immediately after an upper respiratory infection. Light microscopy shows mesangial cell proliferation and crescentic GN. Electron microscopy shows immune deposits in the mesangium. Complement levels are normal. There has been no proven therapy, but ACE inhibitors (ACE-Is), angiotensin receptor blockers (ARBs), fish oil, steroids, and tonsillectomy have been used with some success.¹⁴ The clinical course of IgA nephropathy can be highly variable, with the potential for a benign course to rapidly progressive renal failure, with 15% to 40% of patients developing end-stage renal disease.¹⁴

Henoch-Schonlein purpura. HSP affects children more than adults and is the systemic form of IgA nephropathy.14 Most cases are idiopathic. Clinical

manifestations include: HTN; purpuric palpable rash on buttocks, ankles, and legs; bloody diarrhea with abdominal cramps; and pain in wrist, ankle, and knee joints.¹⁵ Light microscopy shows mesangial cell proliferation. Immune deposits in the mesangium are seen on electron microscopy. Complement levels are normal. Treatment is supportive.

Rapidly progressive glomerulonephritis types I, II, and III. RPGN represents a wide variety of disease states in which rapid progression to renal failure is seen within days to weeks.¹⁶ They are categorized into three sub-categories: I, II, and III.

Type I is an anti-GBM disease, an example being Goodpasture’s syndrome. This condition presents with hemoptysis, pulmonary infiltrates, and hematuria with RBC casts. Anti-GBM antibodies are classically found.¹ Complement levels are normal and a linear immunofluorescence pattern is seen. Treatment is steroids, immunosuppressive agents, and plasmapheresis.¹⁷

Type II is an immune complex deposition disease, such as HSP, SLE, or post-streptococcal GN, in which granular complex deposits are seen. Treatment is directed toward treating the underlying cause.

Type III is pauci-immune (no immune deposits), showing necrotizing crescentic GN on biopsy, and is associated with a positive ANCA.^1,18 They are associated with systemic small-vessel vasculitis, such as granulomatosis with polyangiitis (formerly known as Wegener’s granulomatosis), microscopic polyangiitis, and Churg-Strauss syndrome, or can be limited to renal involvement.^1,18 Complement levels are normal. Treatment is steroids and immunosuppressive agents, such as cyclophosphamide.

A summary of the findings found in the glomerulonephritides and how complement levels are affected are found in Table 2 and Table 3, respectively.

Secondary Causes of Nephrotic Diseases

Diabetic nephropathy. Diabetic nephropathy is the single most common cause of progressive renal failure in the United States.³ Up to 50% of patients with diabetes present with diabetic nephropathy.¹⁹ Current recommendations are to screen yearly for microalbuminuria at the time of diagnosis.³ Treatment involves use of ACE-Is or ARBs to reduce proteinuria and slow the progression of renal disease.

HIV-associated nephropathy. HIV-associated nephropathy commonly presents as the collapsing variant of FSGS. However, it can present as other forms of glomerulopathy, such as MPGN or IgA nephropathy, as well as an immune complex GN with “lupus-like” features without evidence of SLE.^19,20 Therefore, HIV nephropathy has now been categorized as a separate entity.³ ACE-Is, HAART therapy, and corticosteroids are the mainstays of treatment.

Amyloidosis. Renal involvement is seen in both primary (AL) and secondary (AA) amyloidosis. Eighty percent of patients with AL have renal disease, and 25% of these patients have nephrotic syndrome.¹⁶ Diagnosis is made with Congo Red stain, which shows fibrillary amyloid deposits within the mesangium and capillary walls. Treatment is directed at the underlying process.

Systemic lupus erythematosus. SLE is divided into six classes (I-VI) based on the involvement and severity of renal disease, and steroids and immunosuppressive agents are used for treatment, also based on the severity of the disease.²¹

Back to the Case

Our patient presented to the hospital with abdominal pain, low-grade fever, HTN, edema, hypoalbuminemia, and new-onset renal failure with gross hematuria and proteinuria. The presence of proteinuria and hypoalbuminemia, combined with peripheral and periorbital edema, suggests glomerular loss of albumin, such as in nephrotic syndrome. His renal failure in the setting of the sudden development of gross hematuria with flank pain is concerning for a renal vein thrombosis, and an abdominal magnetic resonance venography did in fact visualize a renal vein thrombosis.

He was admitted to the hospital and was started on therapeutic intravenous heparin, and bridged to warfarin. Subsequent renal biopsy confirmed the findings of membranous nephropathy, which was suspected due to his renal vein thrombosis. Therapy was initiated with corticosteroids after the biopsy, and he responded well. Because of his risk factors for further thromboembolic events, lifelong anticoagulation therapy was recommended.

Bottom Line

For patients with glomerular disease, differentiating between nephrotic and nephritic syndromes and understanding key clinical and laboratory differences can lead to easier identification and treatment.

Drs. Khan and Smith are assistant professors of medicine, and Dr. Ansari is associate division director, in the Division of Hospital Medicine at Loyola University Medical Center, Maywood, Ill.

References

1. Donegio RGB, Salant DJ. Nephrology: Glomerular Diseases. In: ACP Medicine. Dale D, Federman D, eds. Available at: http://www.acpmedicine.com/acpmedicine/institutional/instHtmlReader.action?readerFlag=chapt&chapId=part10_ch05. Accessed Feb. 15, 2012.
2. Orth SR, Ritz E. The nephrotic syndrome. N Engl J Med. 1998;338:1202-1211.
3. Lewis JB, Neilson EG. Chapter 283. Glomerular Diseases. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine. 18th ed. New York: McGraw-Hill; 2012.
4. D’Agati VD, Kaskel FJ, Falk RJ. Focal segmental glomerulosclerosis. N Engl J Med. 2011;365:2398-23411.
5. Kitiyakara C, Eggers P, Kopp JB. Twenty-one-year trend in ESRD due to focal segmental glomerulosclerosis in the United States. Am J Kidney Dis. 2004;44:815-825.
6. Balow JE. Nephropathy in the context of HIV infection. Kidney Int. 2005;67:1632-1633.
7. Glassock RJ. Diagnosis and natural course of membranous nephropathy. Semin Nephrol. 2003;23:324-332.
8. Nickolas TL, Radhakrishnan J, Appel GB. Hyperlipidemia and thrombotic complications in patients with membranous nephropathy. Semin Nephrol. 2003;23:406-411.
9. Burstein DM, Korbet SM, Schwartz MM. Membranous glomerulonephritis and malignancy. Am J Kidney Dis. 1993;22:5-10.
10. Hofstra JM, Wetzels JF. Management of patients with membranous nephropathy. Nephrol Dial Transplant. 2012;27:6-9.
11. Alchi B, Jayne D. Membranoproliferative glomerulonephritis. Pediatr Nephrol. 2010;25:1409-1418.
12. Eison TM, Ault BH, Jones DP, Chesney RW, Wyatt RJ. Post-streptococcal acute glomerulonephritis in children: clinical features and pathogenesis. Pediatr Nephrol. 2011;26:165-180.
13. Cohen RA, Brown RS. Clinical practice. Microscopic hematuria. N Engl J Med. 2003;348:2330-2338.
14. Donadio JV, Grande JP. IgA nephropathy. N Engl J Med. 2002;347:738-748.
15. McCarthy HJ, Tizard EJ. Clinical practice: Diagnosis and management of henoch-schonlein purpura. Eur J Pediatr. 2010169:643-650.
16. Appel GB, Radhakrishnan J. Cecil Medicine: Volume 1: Chapter 123: Glomerular Disorders and Nephrotic Syndromes. MD Consult Preview website. Available at: http://www.mdconsult.com/books/page.do?eid=4-u1.0-B978-1-4377-1604-7..00123-8&isbn=978-1-4377-1604-7&uniqId=313771243-2#4-u1.0-B978-1-4377-1604-7..00123-8. Accessed Feb. 16, 2012.
17. Walters G, Willis NS, Craig JC. Interventions for renal vasculitis in adults. Cochrane Database Syst Rev. 2008;(3)(3):CD003232.
18. Jennette JC. Rapidly progressive crescentic glomerulonephritis. Kidney Int. 2003;63:1164-1177.
19. Falk, RJ: Medical Knowledge Self Assessment Program 14. Nephrology: 2006.
20. Haas M, Kaul S, Eustace JA. HIV-associated immune complex glomerulonephritis with “lupus-like” features: a clinicopathologic study of 14 cases. Kidney Int. 2005;67:1381.
21. Dooley MA, Hogan S, Jennette C, Falk R. Cyclophosphamide therapy for lupus nephritis: poor renal survival in black americans. glomerular disease collaborative network. Kidney Int. 1997;51:1188-1195.

click for large version

The Case

A 52-year-old man presents with abdominal pain. His temperature is 100.8°F, his blood pressure is 170/90 mm/Hg, and his pulse is 110 beats per minute. On exam, he has 2+ lower extremity edema, periorbital edema, and left-sided flank tenderness. His BUN is 42 mg/dL, his creatinine is 2.5 mg/dL, and his albumin is 1.4 g/dL. Urinalysis shows 2+ protein, large blood, and red blood cells (RBCs). What are the next steps in his diagnosis?

Overview

Glomerular diseases involve a wide spectrum of disease processes. They can result from an acute illness, such as an upper respiratory infection that self-resolves, or from chronic disease states, such as HIV. In some instances, such illnesses as systemic lupus erythematosus (SLE) can cause rapidly progressive renal failure, requiring prompt intervention. While glomerular diseases can be daunting, it is essential for hospitalists to be familiar with fundamental concepts and key features unique to each syndrome.

The approach to glomerulonephritis (GN) can be simplified by summarizing various types into the two broad categories of nephrotic and nephritic syndromes, and identifying the key clinical findings (see Table 1, p. below).

The major subtypes of nephrotic syndrome are minimal change disease (MCD), focal segmental glomerulosclerosis (FSGS), membranous nephropathy (MN), and membranoproliferative glomerulonephritis (MPGN). The clinical manifestations of nephrotic syndrome are edema, hyperlipidemia, lipiduria, and hypoalbuminemia.1 The urinalysis is significant for >3.5 g/day of proteinuria showing fatty casts or oval fat bodies.² The loss of other proteins, such as anti-thrombin III, may put patients at higher risk for developing venous thromboses.¹

The major subtypes of nephritic syndrome are post-streptococcal glomerulonephritis (PSGS), IgA nephropathy, Henoch-Schonlein Purpura (HSP), and rapidly progressive GN (RPGN types I, II, and III). The clinical manifestations of nephritic syndrome are hypertension (HTN) and hematuria.¹ Nephritic syndromes may present with more rapidly progressive renal failure when compared with nephrotic syndrome.¹ The urinalysis is significant for hematuria with RBC casts, and variable levels of proteinuria (typically, less than 3.5 g/day is seen in nephritic syndrome).¹

Review of the Data

Nephrotic Syndromes

Minimal change disease. MCD is more common in children than adults, and only accounts for 10% to 15% of glomerular disease cases in adults.³ It is associated with Hodgkin’s lymphoma, NSAID use, and allergic conditions. There usually is an absence of hypertension (HTN). There are no glomerular basement membrane abnormalities seen on light microscopy. Electron microscopy shows effacement of podocytes. On urinalysis, oval fat bodies are seen, which are characteristic of heavy proteinuria. Complement levels are normal. Steroids are first-line treatment, but in adults with relapses or steroid resistance, immunosuppressive agents have also been used.²

Focal segment glomerlosclerosis.

FSGS is the most common primary glomerular disorder in the United States and is the most common cause of nephrotic syndrome among blacks.^4,5 It is associated with HIV (collapsing variant), parvovirus B19, heroin use, sickle-cell disease, obesity, chronic vesicoureteral reflux, and HTN.^4,6 Sclerosis of segmental glomeruli is seen on light microscopy.

Electron microscopy shows effacement of podocytes. Complement levels are normal. Treatment of primary idiopathic FSGS includes use of renin-angiotensin inhibitors and steroids.⁴ Immunosuppressives are reserved for relapses. Treatment of secondary FSGS involves identifying the underlying cause.

click for large version

Membranous nephropathy. MN is twice as common in males as in females and is the most common cause of adult-onset idiopathic nephrotic syndrome, with the average presentation in the fifth or sixth decade of life.^7,8 Aside from its idiopathic form, up to 25% of MN cases have an underlying disease process, such as solid organ tumors or hepatitis B.^7,9 While nephrotic syndrome overall can increase the risk of thromboembolic complications, MN is the most common nephrotic disorder predisposing the development of renal vein thrombosis.⁷ Diffuse capillary wall thickening is seen on light microscopy, and electron microscopy shows sub-epithelial immune deposits. Complement levels are normal. Steroids and immunosuppressive agents are used for treatment.¹⁰

Membranoproliferative glomerulonephritis. MPGN is a nephrotic syndrome that is more common in children and young adults and can present with features of nephritic syndrome.^1,11 It is associated with hepatitis C, SLE, and cryoglobulinemia.¹¹ Light microscopy shows mesangial and endocapillary proliferation, as well as glomerular basement membrane thickening and splitting (“tram track” appearance). Electron microscopy shows subendothelial and dense deposits. It presents with reduced complement levels (C3 and C4).¹¹ Treatment depends on the associated disease.

Nephritic Syndromes

Post-streptococcal glomerulonephritis. PSGN is seen in children and young adults and is associated with skin (impetigo) and throat infections (pharyngitis).¹² Hematuria usually presents two to three weeks after a streptococcal infection. The urine is classically dark and smoky-colored. Levels of C3 and CH50 are low, but C4 levels are normal.1 In addition, there are positive antibody titers for ASO and anti-DNase. Light microscopy shows hypercellularity of glomeruli. Electron microscopy shows dome-shaped sub-endothelial deposits. Treatment is usually supportive.

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IgA nephropathy. IgA nephropathy is the most common form of glomerular disease worldwide and the most common form of glomerular-related microscopic hematuria in all age groups.^2,13 It occurs in all ages but more frequently in males.¹⁴ It occurs during or immediately after an upper respiratory infection. Light microscopy shows mesangial cell proliferation and crescentic GN. Electron microscopy shows immune deposits in the mesangium. Complement levels are normal. There has been no proven therapy, but ACE inhibitors (ACE-Is), angiotensin receptor blockers (ARBs), fish oil, steroids, and tonsillectomy have been used with some success.¹⁴ The clinical course of IgA nephropathy can be highly variable, with the potential for a benign course to rapidly progressive renal failure, with 15% to 40% of patients developing end-stage renal disease.¹⁴

Henoch-Schonlein purpura. HSP affects children more than adults and is the systemic form of IgA nephropathy.14 Most cases are idiopathic. Clinical

manifestations include: HTN; purpuric palpable rash on buttocks, ankles, and legs; bloody diarrhea with abdominal cramps; and pain in wrist, ankle, and knee joints.¹⁵ Light microscopy shows mesangial cell proliferation. Immune deposits in the mesangium are seen on electron microscopy. Complement levels are normal. Treatment is supportive.

Rapidly progressive glomerulonephritis types I, II, and III. RPGN represents a wide variety of disease states in which rapid progression to renal failure is seen within days to weeks.¹⁶ They are categorized into three sub-categories: I, II, and III.

Type I is an anti-GBM disease, an example being Goodpasture’s syndrome. This condition presents with hemoptysis, pulmonary infiltrates, and hematuria with RBC casts. Anti-GBM antibodies are classically found.¹ Complement levels are normal and a linear immunofluorescence pattern is seen. Treatment is steroids, immunosuppressive agents, and plasmapheresis.¹⁷

Type II is an immune complex deposition disease, such as HSP, SLE, or post-streptococcal GN, in which granular complex deposits are seen. Treatment is directed toward treating the underlying cause.

Type III is pauci-immune (no immune deposits), showing necrotizing crescentic GN on biopsy, and is associated with a positive ANCA.^1,18 They are associated with systemic small-vessel vasculitis, such as granulomatosis with polyangiitis (formerly known as Wegener’s granulomatosis), microscopic polyangiitis, and Churg-Strauss syndrome, or can be limited to renal involvement.^1,18 Complement levels are normal. Treatment is steroids and immunosuppressive agents, such as cyclophosphamide.

A summary of the findings found in the glomerulonephritides and how complement levels are affected are found in Table 2 and Table 3, respectively.

Secondary Causes of Nephrotic Diseases

Diabetic nephropathy. Diabetic nephropathy is the single most common cause of progressive renal failure in the United States.³ Up to 50% of patients with diabetes present with diabetic nephropathy.¹⁹ Current recommendations are to screen yearly for microalbuminuria at the time of diagnosis.³ Treatment involves use of ACE-Is or ARBs to reduce proteinuria and slow the progression of renal disease.

HIV-associated nephropathy. HIV-associated nephropathy commonly presents as the collapsing variant of FSGS. However, it can present as other forms of glomerulopathy, such as MPGN or IgA nephropathy, as well as an immune complex GN with “lupus-like” features without evidence of SLE.^19,20 Therefore, HIV nephropathy has now been categorized as a separate entity.³ ACE-Is, HAART therapy, and corticosteroids are the mainstays of treatment.

Amyloidosis. Renal involvement is seen in both primary (AL) and secondary (AA) amyloidosis. Eighty percent of patients with AL have renal disease, and 25% of these patients have nephrotic syndrome.¹⁶ Diagnosis is made with Congo Red stain, which shows fibrillary amyloid deposits within the mesangium and capillary walls. Treatment is directed at the underlying process.

Systemic lupus erythematosus. SLE is divided into six classes (I-VI) based on the involvement and severity of renal disease, and steroids and immunosuppressive agents are used for treatment, also based on the severity of the disease.²¹

Back to the Case

Our patient presented to the hospital with abdominal pain, low-grade fever, HTN, edema, hypoalbuminemia, and new-onset renal failure with gross hematuria and proteinuria. The presence of proteinuria and hypoalbuminemia, combined with peripheral and periorbital edema, suggests glomerular loss of albumin, such as in nephrotic syndrome. His renal failure in the setting of the sudden development of gross hematuria with flank pain is concerning for a renal vein thrombosis, and an abdominal magnetic resonance venography did in fact visualize a renal vein thrombosis.

He was admitted to the hospital and was started on therapeutic intravenous heparin, and bridged to warfarin. Subsequent renal biopsy confirmed the findings of membranous nephropathy, which was suspected due to his renal vein thrombosis. Therapy was initiated with corticosteroids after the biopsy, and he responded well. Because of his risk factors for further thromboembolic events, lifelong anticoagulation therapy was recommended.

Bottom Line

For patients with glomerular disease, differentiating between nephrotic and nephritic syndromes and understanding key clinical and laboratory differences can lead to easier identification and treatment.

Drs. Khan and Smith are assistant professors of medicine, and Dr. Ansari is associate division director, in the Division of Hospital Medicine at Loyola University Medical Center, Maywood, Ill.

References

1. Donegio RGB, Salant DJ. Nephrology: Glomerular Diseases. In: ACP Medicine. Dale D, Federman D, eds. Available at: http://www.acpmedicine.com/acpmedicine/institutional/instHtmlReader.action?readerFlag=chapt&chapId=part10_ch05. Accessed Feb. 15, 2012.
2. Orth SR, Ritz E. The nephrotic syndrome. N Engl J Med. 1998;338:1202-1211.
3. Lewis JB, Neilson EG. Chapter 283. Glomerular Diseases. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine. 18th ed. New York: McGraw-Hill; 2012.
4. D’Agati VD, Kaskel FJ, Falk RJ. Focal segmental glomerulosclerosis. N Engl J Med. 2011;365:2398-23411.
5. Kitiyakara C, Eggers P, Kopp JB. Twenty-one-year trend in ESRD due to focal segmental glomerulosclerosis in the United States. Am J Kidney Dis. 2004;44:815-825.
6. Balow JE. Nephropathy in the context of HIV infection. Kidney Int. 2005;67:1632-1633.
7. Glassock RJ. Diagnosis and natural course of membranous nephropathy. Semin Nephrol. 2003;23:324-332.
8. Nickolas TL, Radhakrishnan J, Appel GB. Hyperlipidemia and thrombotic complications in patients with membranous nephropathy. Semin Nephrol. 2003;23:406-411.
9. Burstein DM, Korbet SM, Schwartz MM. Membranous glomerulonephritis and malignancy. Am J Kidney Dis. 1993;22:5-10.
10. Hofstra JM, Wetzels JF. Management of patients with membranous nephropathy. Nephrol Dial Transplant. 2012;27:6-9.
11. Alchi B, Jayne D. Membranoproliferative glomerulonephritis. Pediatr Nephrol. 2010;25:1409-1418.
12. Eison TM, Ault BH, Jones DP, Chesney RW, Wyatt RJ. Post-streptococcal acute glomerulonephritis in children: clinical features and pathogenesis. Pediatr Nephrol. 2011;26:165-180.
13. Cohen RA, Brown RS. Clinical practice. Microscopic hematuria. N Engl J Med. 2003;348:2330-2338.
14. Donadio JV, Grande JP. IgA nephropathy. N Engl J Med. 2002;347:738-748.
15. McCarthy HJ, Tizard EJ. Clinical practice: Diagnosis and management of henoch-schonlein purpura. Eur J Pediatr. 2010169:643-650.
16. Appel GB, Radhakrishnan J. Cecil Medicine: Volume 1: Chapter 123: Glomerular Disorders and Nephrotic Syndromes. MD Consult Preview website. Available at: http://www.mdconsult.com/books/page.do?eid=4-u1.0-B978-1-4377-1604-7..00123-8&isbn=978-1-4377-1604-7&uniqId=313771243-2#4-u1.0-B978-1-4377-1604-7..00123-8. Accessed Feb. 16, 2012.
17. Walters G, Willis NS, Craig JC. Interventions for renal vasculitis in adults. Cochrane Database Syst Rev. 2008;(3)(3):CD003232.
18. Jennette JC. Rapidly progressive crescentic glomerulonephritis. Kidney Int. 2003;63:1164-1177.
19. Falk, RJ: Medical Knowledge Self Assessment Program 14. Nephrology: 2006.
20. Haas M, Kaul S, Eustace JA. HIV-associated immune complex glomerulonephritis with “lupus-like” features: a clinicopathologic study of 14 cases. Kidney Int. 2005;67:1381.
21. Dooley MA, Hogan S, Jennette C, Falk R. Cyclophosphamide therapy for lupus nephritis: poor renal survival in black americans. glomerular disease collaborative network. Kidney Int. 1997;51:1188-1195.

Hospitalists of all stripes owe our new Masters in Hospital Medicine a great debt for their commitment to the specialty, to their patients, and to healthcare.

—Joseph Ming-Wah Li, MD, SFHM, SHM president

If the SHM Award of Excellence winners are the MVPs of HM, then the specialty’s new Masters in Hospital Medicine are this year’s Hall of Famers.

SHM is proud to announce that Patrick J. Cawley, MD, MBA, MHM, Peter K. Lindenauer, MD, MSc, FACP, MHM, and Mark V. Williams, MD, FACP, MHM, have earned the Master in Hospital Medicine designation. They are the eighth, ninth, and 10th SHM members to receive the exclusive designation. In addition to being honored at HM12, they have earned the right to use the “MHM” credential.

“Hospitalists of all stripes owe our new Masters in Hospital Medicine a great debt for their commitment to the specialty, to their patients, and to healthcare,” says Joseph Ming Wah Li, MD, SFHM, SHM president. “Their innovation, leadership, and vision have helped grow the influence and credibility of the hospital medicine specialty.”

Dr. Cawley is a charter member and past president of SHM who has served on the Ethics and Public Policy committees. He is a frequent speaker at the society’s annual meetings. Dr. Cawley received his medical degree from Georgetown University School of Medicine and trained as a resident at Duke University Medical Center, where he also served as an assistant chief resident. He has been a contributing writer to The Hospitalist and several other journals and books.

Dr. Lindenauer is a board-certified internist and founding SHM board member. His research focuses on measuring the quality and outcomes of hospital care for patients with common medical conditions. He is supported by grants from the Agency for Healthcare Research and Quality and the NIH’s National Heart Lung and Blood Institute. His research has appeared in the New England Journal of Medicine, JAMA, Annals of Internal Medicine, Health Affairs, Medical Care, and other general internal medicine and subspecialty journals.

Dr. Williams is professor and chief of the Division of Hospital Medicine at Northwestern University Feinberg School of Medicine in Chicago. He is the principal investigator for SHM’s Project BOOST and is a former SHM president and board member. He has served in numerous leadership roles since the society’s establishment in 1996. In 1998, Dr. Williams established the first hospitalist program at a public hospital, Grady Memorial Hospital in Atlanta.

Drs. Cawley, Lindenauer, and Williams represent the third year of the Masters program. This marks the first year that nominations could be submitted to the SHM Masters Selection committee.

Joining the new masters in earning a new designation are 120 new Fellows in Hospital Medicine (FHM) and 52 Senior Fellows in Hospital Medicine (SFHM). The new members push the fellows program totals to 947 FHMs, 243 SFHMs, and 10 MHMs.

Brendon Shank is SHM’s associate vice president of communications.

Hospitalists of all stripes owe our new Masters in Hospital Medicine a great debt for their commitment to the specialty, to their patients, and to healthcare.

—Joseph Ming-Wah Li, MD, SFHM, SHM president

If the SHM Award of Excellence winners are the MVPs of HM, then the specialty’s new Masters in Hospital Medicine are this year’s Hall of Famers.

SHM is proud to announce that Patrick J. Cawley, MD, MBA, MHM, Peter K. Lindenauer, MD, MSc, FACP, MHM, and Mark V. Williams, MD, FACP, MHM, have earned the Master in Hospital Medicine designation. They are the eighth, ninth, and 10th SHM members to receive the exclusive designation. In addition to being honored at HM12, they have earned the right to use the “MHM” credential.

“Hospitalists of all stripes owe our new Masters in Hospital Medicine a great debt for their commitment to the specialty, to their patients, and to healthcare,” says Joseph Ming Wah Li, MD, SFHM, SHM president. “Their innovation, leadership, and vision have helped grow the influence and credibility of the hospital medicine specialty.”

Dr. Cawley is a charter member and past president of SHM who has served on the Ethics and Public Policy committees. He is a frequent speaker at the society’s annual meetings. Dr. Cawley received his medical degree from Georgetown University School of Medicine and trained as a resident at Duke University Medical Center, where he also served as an assistant chief resident. He has been a contributing writer to The Hospitalist and several other journals and books.

Dr. Lindenauer is a board-certified internist and founding SHM board member. His research focuses on measuring the quality and outcomes of hospital care for patients with common medical conditions. He is supported by grants from the Agency for Healthcare Research and Quality and the NIH’s National Heart Lung and Blood Institute. His research has appeared in the New England Journal of Medicine, JAMA, Annals of Internal Medicine, Health Affairs, Medical Care, and other general internal medicine and subspecialty journals.

Dr. Williams is professor and chief of the Division of Hospital Medicine at Northwestern University Feinberg School of Medicine in Chicago. He is the principal investigator for SHM’s Project BOOST and is a former SHM president and board member. He has served in numerous leadership roles since the society’s establishment in 1996. In 1998, Dr. Williams established the first hospitalist program at a public hospital, Grady Memorial Hospital in Atlanta.

Drs. Cawley, Lindenauer, and Williams represent the third year of the Masters program. This marks the first year that nominations could be submitted to the SHM Masters Selection committee.

Joining the new masters in earning a new designation are 120 new Fellows in Hospital Medicine (FHM) and 52 Senior Fellows in Hospital Medicine (SFHM). The new members push the fellows program totals to 947 FHMs, 243 SFHMs, and 10 MHMs.

Brendon Shank is SHM’s associate vice president of communications.

Hospitalists of all stripes owe our new Masters in Hospital Medicine a great debt for their commitment to the specialty, to their patients, and to healthcare.

—Joseph Ming-Wah Li, MD, SFHM, SHM president

If the SHM Award of Excellence winners are the MVPs of HM, then the specialty’s new Masters in Hospital Medicine are this year’s Hall of Famers.

SHM is proud to announce that Patrick J. Cawley, MD, MBA, MHM, Peter K. Lindenauer, MD, MSc, FACP, MHM, and Mark V. Williams, MD, FACP, MHM, have earned the Master in Hospital Medicine designation. They are the eighth, ninth, and 10th SHM members to receive the exclusive designation. In addition to being honored at HM12, they have earned the right to use the “MHM” credential.

“Hospitalists of all stripes owe our new Masters in Hospital Medicine a great debt for their commitment to the specialty, to their patients, and to healthcare,” says Joseph Ming Wah Li, MD, SFHM, SHM president. “Their innovation, leadership, and vision have helped grow the influence and credibility of the hospital medicine specialty.”

Dr. Cawley is a charter member and past president of SHM who has served on the Ethics and Public Policy committees. He is a frequent speaker at the society’s annual meetings. Dr. Cawley received his medical degree from Georgetown University School of Medicine and trained as a resident at Duke University Medical Center, where he also served as an assistant chief resident. He has been a contributing writer to The Hospitalist and several other journals and books.

Dr. Lindenauer is a board-certified internist and founding SHM board member. His research focuses on measuring the quality and outcomes of hospital care for patients with common medical conditions. He is supported by grants from the Agency for Healthcare Research and Quality and the NIH’s National Heart Lung and Blood Institute. His research has appeared in the New England Journal of Medicine, JAMA, Annals of Internal Medicine, Health Affairs, Medical Care, and other general internal medicine and subspecialty journals.

Dr. Williams is professor and chief of the Division of Hospital Medicine at Northwestern University Feinberg School of Medicine in Chicago. He is the principal investigator for SHM’s Project BOOST and is a former SHM president and board member. He has served in numerous leadership roles since the society’s establishment in 1996. In 1998, Dr. Williams established the first hospitalist program at a public hospital, Grady Memorial Hospital in Atlanta.

Drs. Cawley, Lindenauer, and Williams represent the third year of the Masters program. This marks the first year that nominations could be submitted to the SHM Masters Selection committee.

Joining the new masters in earning a new designation are 120 new Fellows in Hospital Medicine (FHM) and 52 Senior Fellows in Hospital Medicine (SFHM). The new members push the fellows program totals to 947 FHMs, 243 SFHMs, and 10 MHMs.

Brendon Shank is SHM’s associate vice president of communications.

The 2012 award winners are blazing new paths for hospitalists and hospitals. They inspire us to find new ways to raise the bar higher when it comes to providing care in the hospital and, at the same time, improving the hospital itself.

—Joseph Ming-Wah Li, MD, SFHM, SHM president

Hospitalists across the country are taking the lead—leading their HM groups, leading care teams, and leading quality-improvement (QI) efforts.

With this year’s annual SHM Awards of Excellence, thousands of hospitalists at HM12 saluted the leaders in the specialty. Five individuals and one team were recognized at the San Diego Convention Center for their efforts to transform healthcare and revolutionize patient care.

In addition to being recognized at HM12, the honorees were the subjects of a video presented at HM12 and posted on SHM’s YouTube channel.

Brendon Shank is associate vice president of communications at SHM

The 2012 SHM Award of Excellence winners are:

Excellence in Teamwork and Quality Improvement

The In-Hospital Stroke QI Team at the University of Colorado Hospital, led by Ethan Cumbler, MD, FACP, associate professor of medicine and hospitalist at University of Colorado Hospital, was recognized for exemplary quality improvement initiatives in hospital medicine that engage the full patient care team.

Excellence in Hospital Medicine for Non-Physicians

Jina Saltzman, physician assistant, University of Chicago.

Outstanding Service in Hospital Medicine

William D. Atchley Jr., MD, FACP, SFHM, regional senior medical director, Eagle Hospital Physicians.

Excellence in Teaching

Jeff Barsuk, MD, MS, FHM, associate professor of medicine, Northwestern University Feinberg School of Medicine, Chicago.

Clinical Excellence

Douglas W. Carlson, MD, SFHM, professor of pediatrics and director of the Division of Pediatric Hospital Medicine at Washington University and St. Louis Children’s Hospital.

Excellence in Research

Ron Keren, MD, MPH, associate professor of pediatrics and epidemiology, The Children’s Hospital of Philadelphia, and the University of Pennsylvania School of Medicine.

The 2012 award winners are blazing new paths for hospitalists and hospitals. They inspire us to find new ways to raise the bar higher when it comes to providing care in the hospital and, at the same time, improving the hospital itself.

—Joseph Ming-Wah Li, MD, SFHM, SHM president

Hospitalists across the country are taking the lead—leading their HM groups, leading care teams, and leading quality-improvement (QI) efforts.

With this year’s annual SHM Awards of Excellence, thousands of hospitalists at HM12 saluted the leaders in the specialty. Five individuals and one team were recognized at the San Diego Convention Center for their efforts to transform healthcare and revolutionize patient care.

In addition to being recognized at HM12, the honorees were the subjects of a video presented at HM12 and posted on SHM’s YouTube channel.

Brendon Shank is associate vice president of communications at SHM

The 2012 SHM Award of Excellence winners are:

Excellence in Teamwork and Quality Improvement

The In-Hospital Stroke QI Team at the University of Colorado Hospital, led by Ethan Cumbler, MD, FACP, associate professor of medicine and hospitalist at University of Colorado Hospital, was recognized for exemplary quality improvement initiatives in hospital medicine that engage the full patient care team.

Excellence in Hospital Medicine for Non-Physicians

Jina Saltzman, physician assistant, University of Chicago.

Outstanding Service in Hospital Medicine

William D. Atchley Jr., MD, FACP, SFHM, regional senior medical director, Eagle Hospital Physicians.

Excellence in Teaching

Jeff Barsuk, MD, MS, FHM, associate professor of medicine, Northwestern University Feinberg School of Medicine, Chicago.

Clinical Excellence

Douglas W. Carlson, MD, SFHM, professor of pediatrics and director of the Division of Pediatric Hospital Medicine at Washington University and St. Louis Children’s Hospital.

Excellence in Research

Ron Keren, MD, MPH, associate professor of pediatrics and epidemiology, The Children’s Hospital of Philadelphia, and the University of Pennsylvania School of Medicine.

The 2012 award winners are blazing new paths for hospitalists and hospitals. They inspire us to find new ways to raise the bar higher when it comes to providing care in the hospital and, at the same time, improving the hospital itself.

—Joseph Ming-Wah Li, MD, SFHM, SHM president

Hospitalists across the country are taking the lead—leading their HM groups, leading care teams, and leading quality-improvement (QI) efforts.

With this year’s annual SHM Awards of Excellence, thousands of hospitalists at HM12 saluted the leaders in the specialty. Five individuals and one team were recognized at the San Diego Convention Center for their efforts to transform healthcare and revolutionize patient care.

In addition to being recognized at HM12, the honorees were the subjects of a video presented at HM12 and posted on SHM’s YouTube channel.

Brendon Shank is associate vice president of communications at SHM

The 2012 SHM Award of Excellence winners are:

Excellence in Teamwork and Quality Improvement

The In-Hospital Stroke QI Team at the University of Colorado Hospital, led by Ethan Cumbler, MD, FACP, associate professor of medicine and hospitalist at University of Colorado Hospital, was recognized for exemplary quality improvement initiatives in hospital medicine that engage the full patient care team.

Excellence in Hospital Medicine for Non-Physicians

Jina Saltzman, physician assistant, University of Chicago.

Outstanding Service in Hospital Medicine

William D. Atchley Jr., MD, FACP, SFHM, regional senior medical director, Eagle Hospital Physicians.

Excellence in Teaching

Jeff Barsuk, MD, MS, FHM, associate professor of medicine, Northwestern University Feinberg School of Medicine, Chicago.

Clinical Excellence

Douglas W. Carlson, MD, SFHM, professor of pediatrics and director of the Division of Pediatric Hospital Medicine at Washington University and St. Louis Children’s Hospital.

Excellence in Research

Ron Keren, MD, MPH, associate professor of pediatrics and epidemiology, The Children’s Hospital of Philadelphia, and the University of Pennsylvania School of Medicine.

Every year, primary-care physicians (PCPs) and hospitalists struggle to manage care for complex medically ill patients, according to a new survey conducted by SHM and QuantiaMD.

Complex medically ill patients have two or more concurrent chronic conditions that require ongoing medical attention or limit activities of daily living. These 4 million patients, which make up 10% of the Medicare population, consume a disproportionate amount of acute healthcare resources, accounting for up to 20% of ED visits, and have significantly higher likelihood of hospital admission and readmission, according to the survey.¹ This presents a challenge to both inpatient and outpatient providers charged with coordinating their care.

SHM, in partnership with QuantiaMD, conducted a survey of nearly 4,000 physicians about this topic, which has resulted in a white paper and online expert series to outline opportunities and feature innovative examples to improve patient care of the complex medically ill.

“Communication greatly impacts quality of care and the ability to prevent excess hospital admissions and readmissions,” says Michael Radzienda, MD, SFHM, principal investigator for the Medically Complex Ill Project. “Findings from the study identified barriers to timely and effective communication on the health team who care for the medically complex ill and opportunities to implement the latest innovations to improve patient care and safety.”

A new expert practice series in the reducing readmissions special-interest group from SHM and QuantiaMD, “Innovations in Care Coordination for the Complex Medically Ill,” grew from the study and provides best practices, and also features actual case studies of existing care-coordination efforts. This online interactive forum is the first of its kind, providing resources to address care-coordination challenges that have plagued patient care over the past decade. The series includes nine presentations on topics including patient-centered medical homes, telemedicine, and post-discharge clinics.

Reference

1. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428.

Every year, primary-care physicians (PCPs) and hospitalists struggle to manage care for complex medically ill patients, according to a new survey conducted by SHM and QuantiaMD.

Complex medically ill patients have two or more concurrent chronic conditions that require ongoing medical attention or limit activities of daily living. These 4 million patients, which make up 10% of the Medicare population, consume a disproportionate amount of acute healthcare resources, accounting for up to 20% of ED visits, and have significantly higher likelihood of hospital admission and readmission, according to the survey.¹ This presents a challenge to both inpatient and outpatient providers charged with coordinating their care.

SHM, in partnership with QuantiaMD, conducted a survey of nearly 4,000 physicians about this topic, which has resulted in a white paper and online expert series to outline opportunities and feature innovative examples to improve patient care of the complex medically ill.

“Communication greatly impacts quality of care and the ability to prevent excess hospital admissions and readmissions,” says Michael Radzienda, MD, SFHM, principal investigator for the Medically Complex Ill Project. “Findings from the study identified barriers to timely and effective communication on the health team who care for the medically complex ill and opportunities to implement the latest innovations to improve patient care and safety.”

A new expert practice series in the reducing readmissions special-interest group from SHM and QuantiaMD, “Innovations in Care Coordination for the Complex Medically Ill,” grew from the study and provides best practices, and also features actual case studies of existing care-coordination efforts. This online interactive forum is the first of its kind, providing resources to address care-coordination challenges that have plagued patient care over the past decade. The series includes nine presentations on topics including patient-centered medical homes, telemedicine, and post-discharge clinics.

Reference

1. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428.

Every year, primary-care physicians (PCPs) and hospitalists struggle to manage care for complex medically ill patients, according to a new survey conducted by SHM and QuantiaMD.

Complex medically ill patients have two or more concurrent chronic conditions that require ongoing medical attention or limit activities of daily living. These 4 million patients, which make up 10% of the Medicare population, consume a disproportionate amount of acute healthcare resources, accounting for up to 20% of ED visits, and have significantly higher likelihood of hospital admission and readmission, according to the survey.¹ This presents a challenge to both inpatient and outpatient providers charged with coordinating their care.

SHM, in partnership with QuantiaMD, conducted a survey of nearly 4,000 physicians about this topic, which has resulted in a white paper and online expert series to outline opportunities and feature innovative examples to improve patient care of the complex medically ill.

“Communication greatly impacts quality of care and the ability to prevent excess hospital admissions and readmissions,” says Michael Radzienda, MD, SFHM, principal investigator for the Medically Complex Ill Project. “Findings from the study identified barriers to timely and effective communication on the health team who care for the medically complex ill and opportunities to implement the latest innovations to improve patient care and safety.”

A new expert practice series in the reducing readmissions special-interest group from SHM and QuantiaMD, “Innovations in Care Coordination for the Complex Medically Ill,” grew from the study and provides best practices, and also features actual case studies of existing care-coordination efforts. This online interactive forum is the first of its kind, providing resources to address care-coordination challenges that have plagued patient care over the past decade. The series includes nine presentations on topics including patient-centered medical homes, telemedicine, and post-discharge clinics.

Reference

1. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-1428.

SHM recently joined more than 30 organizations in the Council of Medical Specialty Societies (CMSS) in signing a letter to the Centers for Medicare & Medicaid Services (CMS) to affirm the importance of—and to voice concerns about—some provisions in the proposed Sunshine Rule for doctor-industry relationships.

Specifically, the letter highlights some critical distinctions in compensation for teaching Continuing Medical Education (CME) courses.

The Sunshine Rule was proposed in response to the adoption of the Physician Payments Sunshine Act in Section 6002 of the Affordable Care Act of 2010. The act requires gifts or payments to physicians from pharmaceutical and medical device manufacturers worth more than $10 to be reported publicly by manufacturers. CMS created the proposed rule to frame which situations and exchanges of value fall within and outside the reporting requirements. As part of the rulemaking process, CMS welcomed comments to help refine and develop the final rule.

The proposed rule asserts that the category of “Direct Compensation for Serving as a Faculty or as a Speaker for a Medical Education Program” be broadly understood to encompass any situation in which a manufacturer compensates physicians for speaking engagements. This includes certain indirect payments through a third-party like a CME provider. So if you serve as a faculty member sharing your expertise through accredited or certified CME, your service could be reportable if the provider received industry funding. This could happen even if you have no specific knowledge of the industry funder.

The CMSS letter identifies a distinction between promotional education programs and accredited or certified CME programs, noting that only the former implies a relationship between a physician and manufacturer. Accredited and certified CME programs, on the other hand, already are governed by the Standards for Commercial Support: Standards to Ensure the Independence of CME Activities, which includes guidance to ensure the independence of CME activities from industry funders. Industry grants do not pay accredited or certified CME faculty directly, but rather go to CME providers who organize and develop the programs. This clarification expressly acknowledges the established self-regulation and ethical guidelines of the CME programs. Importantly, the letter does support disclosure of compensation from promotional education programs directly sponsored by industry.

By signing on to this letter, SHM has expressed its support for greater transparency in relationships between physicians and industries, while illuminating areas of concern in the rule.

The Sunshine Rule illustrates some of the richness and complexity of policy initiatives, and highlights potential topics to broaden our conversation and involvement. These types of issues generate robust discussions about ethics and professionalism within the medical establishment.

Hospitalists can, and should, engage these debates both within SHM and from their unique vantage point within the hospital.

As a membership organization, SHM details our efforts at transparency in our relationship with industry partners at www.hospitalmedicine.org/industry.

SHM recently joined more than 30 organizations in the Council of Medical Specialty Societies (CMSS) in signing a letter to the Centers for Medicare & Medicaid Services (CMS) to affirm the importance of—and to voice concerns about—some provisions in the proposed Sunshine Rule for doctor-industry relationships.

Specifically, the letter highlights some critical distinctions in compensation for teaching Continuing Medical Education (CME) courses.

The Sunshine Rule was proposed in response to the adoption of the Physician Payments Sunshine Act in Section 6002 of the Affordable Care Act of 2010. The act requires gifts or payments to physicians from pharmaceutical and medical device manufacturers worth more than $10 to be reported publicly by manufacturers. CMS created the proposed rule to frame which situations and exchanges of value fall within and outside the reporting requirements. As part of the rulemaking process, CMS welcomed comments to help refine and develop the final rule.

The proposed rule asserts that the category of “Direct Compensation for Serving as a Faculty or as a Speaker for a Medical Education Program” be broadly understood to encompass any situation in which a manufacturer compensates physicians for speaking engagements. This includes certain indirect payments through a third-party like a CME provider. So if you serve as a faculty member sharing your expertise through accredited or certified CME, your service could be reportable if the provider received industry funding. This could happen even if you have no specific knowledge of the industry funder.

The CMSS letter identifies a distinction between promotional education programs and accredited or certified CME programs, noting that only the former implies a relationship between a physician and manufacturer. Accredited and certified CME programs, on the other hand, already are governed by the Standards for Commercial Support: Standards to Ensure the Independence of CME Activities, which includes guidance to ensure the independence of CME activities from industry funders. Industry grants do not pay accredited or certified CME faculty directly, but rather go to CME providers who organize and develop the programs. This clarification expressly acknowledges the established self-regulation and ethical guidelines of the CME programs. Importantly, the letter does support disclosure of compensation from promotional education programs directly sponsored by industry.

By signing on to this letter, SHM has expressed its support for greater transparency in relationships between physicians and industries, while illuminating areas of concern in the rule.

The Sunshine Rule illustrates some of the richness and complexity of policy initiatives, and highlights potential topics to broaden our conversation and involvement. These types of issues generate robust discussions about ethics and professionalism within the medical establishment.

Hospitalists can, and should, engage these debates both within SHM and from their unique vantage point within the hospital.

As a membership organization, SHM details our efforts at transparency in our relationship with industry partners at www.hospitalmedicine.org/industry.

SHM recently joined more than 30 organizations in the Council of Medical Specialty Societies (CMSS) in signing a letter to the Centers for Medicare & Medicaid Services (CMS) to affirm the importance of—and to voice concerns about—some provisions in the proposed Sunshine Rule for doctor-industry relationships.

Specifically, the letter highlights some critical distinctions in compensation for teaching Continuing Medical Education (CME) courses.

The Sunshine Rule was proposed in response to the adoption of the Physician Payments Sunshine Act in Section 6002 of the Affordable Care Act of 2010. The act requires gifts or payments to physicians from pharmaceutical and medical device manufacturers worth more than $10 to be reported publicly by manufacturers. CMS created the proposed rule to frame which situations and exchanges of value fall within and outside the reporting requirements. As part of the rulemaking process, CMS welcomed comments to help refine and develop the final rule.

The proposed rule asserts that the category of “Direct Compensation for Serving as a Faculty or as a Speaker for a Medical Education Program” be broadly understood to encompass any situation in which a manufacturer compensates physicians for speaking engagements. This includes certain indirect payments through a third-party like a CME provider. So if you serve as a faculty member sharing your expertise through accredited or certified CME, your service could be reportable if the provider received industry funding. This could happen even if you have no specific knowledge of the industry funder.

The CMSS letter identifies a distinction between promotional education programs and accredited or certified CME programs, noting that only the former implies a relationship between a physician and manufacturer. Accredited and certified CME programs, on the other hand, already are governed by the Standards for Commercial Support: Standards to Ensure the Independence of CME Activities, which includes guidance to ensure the independence of CME activities from industry funders. Industry grants do not pay accredited or certified CME faculty directly, but rather go to CME providers who organize and develop the programs. This clarification expressly acknowledges the established self-regulation and ethical guidelines of the CME programs. Importantly, the letter does support disclosure of compensation from promotional education programs directly sponsored by industry.

By signing on to this letter, SHM has expressed its support for greater transparency in relationships between physicians and industries, while illuminating areas of concern in the rule.

The Sunshine Rule illustrates some of the richness and complexity of policy initiatives, and highlights potential topics to broaden our conversation and involvement. These types of issues generate robust discussions about ethics and professionalism within the medical establishment.

Hospitalists can, and should, engage these debates both within SHM and from their unique vantage point within the hospital.

As a membership organization, SHM details our efforts at transparency in our relationship with industry partners at www.hospitalmedicine.org/industry.

Partnership for Patients brings a spotlight and an energy to the issue that will last long beyond the 24 months of this program.

—Katharine Luther, RN, MPM, vice president of hospital portfolio planning and administration, Institute for Healthcare Improvement

Last April, the Centers for Medicare & Medicaid Services (CMS) unveiled “Partnership for Patients,” a landmark event in the patient safety movement that put a national spotlight on the continuing need to improve healthcare safety and quality. A year later, the initiative is getting off the ground, attempting to tackle ambitious goals and overcome methodological hurdles in a very tight timeframe.

Partnership for Patients is a $1 billion, nationwide educational collaborative in which participants pledge that they will try to achieve two things by the end of 2013: Reduce the incidence of preventable hospital-acquired conditions by 40% compared to 2010, and decrease preventable complications during transitions of care to reduce hospital readmissions by 20% compared with 2010.

More than 3,000 hospitals and 2,000 physician and nursing organizations have signed the pledge, and CMS recently awarded contracts to 26 Hospital Engagement Networks (HENs)—state, regional, and national hospitals and health systems that will serve as mobile classrooms that mentor as they implement new intervention strategies, track progress on quality improvement (QI), and develop learning collaboratives to spread effective interventions. CMS also has contracted with outside firms to create patient safety training materials, engage with patients and families to foster more patient-centered care, and evaluate the impact and effectiveness of the initiative.

SHM was one of the first physician groups to sign on to the initiative’s pledge of support, and both its Project BOOST (to reduce preventable readmissions) and its VTE Resource Room (to prevent hospital-acquired venous thromboembolism) are among the resources it is making available to the initiative’s HENs, says Wendy Nickel, MPH, associate vice president of SHM’s Center for Hospital Innovation and Improvement.

Worthy Goals

Despite success stories at some institutions in recent years, patient safety improvement still has far to go at U.S. hospitals. Currently, about 1 in every 20 patients acquires an infection in the hospital, 1 in 7 Medicare patients is harmed in the course of their hospital care, and nearly 1 in 5 is readmitted within 30 days of discharge. CMS estimates that meeting the goals of Partnership for Patients would mean more than 60,000 lives saved over the next three years and over 1.6 million patients spared a preventable complication requiring re-hospitalization within 30 days of discharge—all of which could save Medicare $50 billion over the next 10 years.¹

Formidable Obstacles

While the initiative’s goals are certainly worthy, it remains to be seen how prepared hospitals are to achieve them, and whether available metrics are up to the task.

“The initiative is a positive step to improve collaboration among government, communities, and hospital sites in service of better patient care and safety—and so it deserves our endorsement,” says Greg Maynard, MD, MSc, SFHM, health sciences professor of medicine at the University of California at San Diego, director of the UC San Diego Center for Innovation and Improvement Science, and senior vice president of SHM’s Center for Hospital Innovation and Improvement. “But it’s an open question how successful it will be, since it offers no monetary piece of the pie to participating hospitals, and no financial penalties for failing to achieve its goals. The whole project feels rushed, for a major initiative like this, with such ambitious goals.”

The primary “carrot” the initiative offers hospitals, Dr. Maynard notes, is access to patient safety improvement expertise and resources that they would otherwise have to purchase on their own, including training materials, implementation guides, webinars, and site visits by HEN representatives.

As an indirect inducement to participate, CMS’ Hospital Readmissions Reduction Program begins this October and will penalize hospitals by as much as 1% of their total Medicare billings (increasing to 3% in 2015) for high rates of readmissions related to heart attack, heart failure, and pneumonia. CMS’ Value-Based Purchasing program also continues to reward and punish hospitals for their performance on core measures and patient satisfaction, with more metrics forthcoming.

Metric Morass

A major challenge to the success of Partnership for Patients will be the ability to formulate and share reliable, uniform patient safety metrics across institutions. The initiative gives each of the 26 HENs the flexibility to tailor their activities to the sites they are mentoring, and there is no clear way of making standardized comparisons of hospital performance across the HENs, Dr. Maynard says.

Metric validity is a crucial component of any QI initiative. And yet, the ability to reliably measure patient harm/adverse event rates at hospitals—and therefore achieving a solid “denominator” baseline with which to track progress—remains elusive. In a recent report, the U.S. Department of Health and Human Services’ Office of the Inspector General noted that hospital incident reporting systems capture only an estimated 14% of the patient harm events experienced by Medicare patients, reporting requirements remain unclear, and hospital staff continue to harbor misperceptions about what constitutes patient harm.²

In what almost sounds like “back to the drawing board,” the report recommended that CMS and the Agency for Healthcare Research and Quality (AHRQ) collaborate to create and promote a list of potentially reportable events for hospitals to use, and that CMS provide guidance to accreditors regarding their assessments of hospital efforts to track and analyze events.

The problem is that voluntary incident reporting systems are only one tool for identifying patient harm. Typically, however, they miss many things that can harm patients and are grossly under-reported. As a result, they need to be used in conjunction with other data sources, such as hospital infection rates, daily safety rounding on hospital units, and patient chart sampling, says Katharine Luther, RN, MPM, the Institute for Healthcare Improvement’s vice president of hospital portfolio planning and administration.

Another excellent surveillance instrument for capturing a count of possible harm events is a Global Trigger Tool, which samples patient charts to identify aberrant lab values, drug dosages, and other untoward events that might indicate harm, even though they might not easily be recognized as harmful by hospital staff, Luther says.

Warranted Optimism

Despite its aggressive timeline and inherent methodological challenges, Luther says the Partnership for Patients will galvanize and focus hospitals’ patient safety improvement efforts and provide a much-needed framework for implementation.

“We know of organizations that have greatly reduced the incidence of pressure ulcers, and have gone for a year or more with no cases of ventilator-associated pneumonia or central-line-associated bloodstream infection (CLABSI),” Luther says. “Exemplars like these are out there, so it can be done. Partnership for Patients brings a spotlight and an energy to the issue that will last long beyond the 24 months of this program.”

Chris Guadagnino is a freelance medical writer in Philadelphia.

References

1. CMS Fact Sheet. Hospital Engagement Networks: Connecting Hospitals to Improve Care. Centers for Medicare & Medicaid website. Available at: http://www.cms.gov/apps/media/press/factsheet.asp?Counter=4219&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date. Accessed Feb. 12, 2012.
2. HHS Office of Inspector General. Hospital Incident Reporting Systems Do Not Capture Most Patient Harm. Office of Inspector General website. Available at: http://oig.hhs.gov/oei/reports/oei-06-09-00091.pdf. Accessed Feb. 12, 2012.

Partnership for Patients brings a spotlight and an energy to the issue that will last long beyond the 24 months of this program.

—Katharine Luther, RN, MPM, vice president of hospital portfolio planning and administration, Institute for Healthcare Improvement

Last April, the Centers for Medicare & Medicaid Services (CMS) unveiled “Partnership for Patients,” a landmark event in the patient safety movement that put a national spotlight on the continuing need to improve healthcare safety and quality. A year later, the initiative is getting off the ground, attempting to tackle ambitious goals and overcome methodological hurdles in a very tight timeframe.

Partnership for Patients is a $1 billion, nationwide educational collaborative in which participants pledge that they will try to achieve two things by the end of 2013: Reduce the incidence of preventable hospital-acquired conditions by 40% compared to 2010, and decrease preventable complications during transitions of care to reduce hospital readmissions by 20% compared with 2010.

More than 3,000 hospitals and 2,000 physician and nursing organizations have signed the pledge, and CMS recently awarded contracts to 26 Hospital Engagement Networks (HENs)—state, regional, and national hospitals and health systems that will serve as mobile classrooms that mentor as they implement new intervention strategies, track progress on quality improvement (QI), and develop learning collaboratives to spread effective interventions. CMS also has contracted with outside firms to create patient safety training materials, engage with patients and families to foster more patient-centered care, and evaluate the impact and effectiveness of the initiative.

SHM was one of the first physician groups to sign on to the initiative’s pledge of support, and both its Project BOOST (to reduce preventable readmissions) and its VTE Resource Room (to prevent hospital-acquired venous thromboembolism) are among the resources it is making available to the initiative’s HENs, says Wendy Nickel, MPH, associate vice president of SHM’s Center for Hospital Innovation and Improvement.

Worthy Goals

Despite success stories at some institutions in recent years, patient safety improvement still has far to go at U.S. hospitals. Currently, about 1 in every 20 patients acquires an infection in the hospital, 1 in 7 Medicare patients is harmed in the course of their hospital care, and nearly 1 in 5 is readmitted within 30 days of discharge. CMS estimates that meeting the goals of Partnership for Patients would mean more than 60,000 lives saved over the next three years and over 1.6 million patients spared a preventable complication requiring re-hospitalization within 30 days of discharge—all of which could save Medicare $50 billion over the next 10 years.¹

Formidable Obstacles

While the initiative’s goals are certainly worthy, it remains to be seen how prepared hospitals are to achieve them, and whether available metrics are up to the task.

“The initiative is a positive step to improve collaboration among government, communities, and hospital sites in service of better patient care and safety—and so it deserves our endorsement,” says Greg Maynard, MD, MSc, SFHM, health sciences professor of medicine at the University of California at San Diego, director of the UC San Diego Center for Innovation and Improvement Science, and senior vice president of SHM’s Center for Hospital Innovation and Improvement. “But it’s an open question how successful it will be, since it offers no monetary piece of the pie to participating hospitals, and no financial penalties for failing to achieve its goals. The whole project feels rushed, for a major initiative like this, with such ambitious goals.”

The primary “carrot” the initiative offers hospitals, Dr. Maynard notes, is access to patient safety improvement expertise and resources that they would otherwise have to purchase on their own, including training materials, implementation guides, webinars, and site visits by HEN representatives.

As an indirect inducement to participate, CMS’ Hospital Readmissions Reduction Program begins this October and will penalize hospitals by as much as 1% of their total Medicare billings (increasing to 3% in 2015) for high rates of readmissions related to heart attack, heart failure, and pneumonia. CMS’ Value-Based Purchasing program also continues to reward and punish hospitals for their performance on core measures and patient satisfaction, with more metrics forthcoming.

Metric Morass

A major challenge to the success of Partnership for Patients will be the ability to formulate and share reliable, uniform patient safety metrics across institutions. The initiative gives each of the 26 HENs the flexibility to tailor their activities to the sites they are mentoring, and there is no clear way of making standardized comparisons of hospital performance across the HENs, Dr. Maynard says.

Metric validity is a crucial component of any QI initiative. And yet, the ability to reliably measure patient harm/adverse event rates at hospitals—and therefore achieving a solid “denominator” baseline with which to track progress—remains elusive. In a recent report, the U.S. Department of Health and Human Services’ Office of the Inspector General noted that hospital incident reporting systems capture only an estimated 14% of the patient harm events experienced by Medicare patients, reporting requirements remain unclear, and hospital staff continue to harbor misperceptions about what constitutes patient harm.²

In what almost sounds like “back to the drawing board,” the report recommended that CMS and the Agency for Healthcare Research and Quality (AHRQ) collaborate to create and promote a list of potentially reportable events for hospitals to use, and that CMS provide guidance to accreditors regarding their assessments of hospital efforts to track and analyze events.

The problem is that voluntary incident reporting systems are only one tool for identifying patient harm. Typically, however, they miss many things that can harm patients and are grossly under-reported. As a result, they need to be used in conjunction with other data sources, such as hospital infection rates, daily safety rounding on hospital units, and patient chart sampling, says Katharine Luther, RN, MPM, the Institute for Healthcare Improvement’s vice president of hospital portfolio planning and administration.

Another excellent surveillance instrument for capturing a count of possible harm events is a Global Trigger Tool, which samples patient charts to identify aberrant lab values, drug dosages, and other untoward events that might indicate harm, even though they might not easily be recognized as harmful by hospital staff, Luther says.

Warranted Optimism

Despite its aggressive timeline and inherent methodological challenges, Luther says the Partnership for Patients will galvanize and focus hospitals’ patient safety improvement efforts and provide a much-needed framework for implementation.

“We know of organizations that have greatly reduced the incidence of pressure ulcers, and have gone for a year or more with no cases of ventilator-associated pneumonia or central-line-associated bloodstream infection (CLABSI),” Luther says. “Exemplars like these are out there, so it can be done. Partnership for Patients brings a spotlight and an energy to the issue that will last long beyond the 24 months of this program.”

Chris Guadagnino is a freelance medical writer in Philadelphia.

References

1. CMS Fact Sheet. Hospital Engagement Networks: Connecting Hospitals to Improve Care. Centers for Medicare & Medicaid website. Available at: http://www.cms.gov/apps/media/press/factsheet.asp?Counter=4219&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date. Accessed Feb. 12, 2012.
2. HHS Office of Inspector General. Hospital Incident Reporting Systems Do Not Capture Most Patient Harm. Office of Inspector General website. Available at: http://oig.hhs.gov/oei/reports/oei-06-09-00091.pdf. Accessed Feb. 12, 2012.

Partnership for Patients brings a spotlight and an energy to the issue that will last long beyond the 24 months of this program.

—Katharine Luther, RN, MPM, vice president of hospital portfolio planning and administration, Institute for Healthcare Improvement

Last April, the Centers for Medicare & Medicaid Services (CMS) unveiled “Partnership for Patients,” a landmark event in the patient safety movement that put a national spotlight on the continuing need to improve healthcare safety and quality. A year later, the initiative is getting off the ground, attempting to tackle ambitious goals and overcome methodological hurdles in a very tight timeframe.

Partnership for Patients is a $1 billion, nationwide educational collaborative in which participants pledge that they will try to achieve two things by the end of 2013: Reduce the incidence of preventable hospital-acquired conditions by 40% compared to 2010, and decrease preventable complications during transitions of care to reduce hospital readmissions by 20% compared with 2010.

More than 3,000 hospitals and 2,000 physician and nursing organizations have signed the pledge, and CMS recently awarded contracts to 26 Hospital Engagement Networks (HENs)—state, regional, and national hospitals and health systems that will serve as mobile classrooms that mentor as they implement new intervention strategies, track progress on quality improvement (QI), and develop learning collaboratives to spread effective interventions. CMS also has contracted with outside firms to create patient safety training materials, engage with patients and families to foster more patient-centered care, and evaluate the impact and effectiveness of the initiative.

SHM was one of the first physician groups to sign on to the initiative’s pledge of support, and both its Project BOOST (to reduce preventable readmissions) and its VTE Resource Room (to prevent hospital-acquired venous thromboembolism) are among the resources it is making available to the initiative’s HENs, says Wendy Nickel, MPH, associate vice president of SHM’s Center for Hospital Innovation and Improvement.

Worthy Goals

Despite success stories at some institutions in recent years, patient safety improvement still has far to go at U.S. hospitals. Currently, about 1 in every 20 patients acquires an infection in the hospital, 1 in 7 Medicare patients is harmed in the course of their hospital care, and nearly 1 in 5 is readmitted within 30 days of discharge. CMS estimates that meeting the goals of Partnership for Patients would mean more than 60,000 lives saved over the next three years and over 1.6 million patients spared a preventable complication requiring re-hospitalization within 30 days of discharge—all of which could save Medicare $50 billion over the next 10 years.¹

Formidable Obstacles

While the initiative’s goals are certainly worthy, it remains to be seen how prepared hospitals are to achieve them, and whether available metrics are up to the task.

“The initiative is a positive step to improve collaboration among government, communities, and hospital sites in service of better patient care and safety—and so it deserves our endorsement,” says Greg Maynard, MD, MSc, SFHM, health sciences professor of medicine at the University of California at San Diego, director of the UC San Diego Center for Innovation and Improvement Science, and senior vice president of SHM’s Center for Hospital Innovation and Improvement. “But it’s an open question how successful it will be, since it offers no monetary piece of the pie to participating hospitals, and no financial penalties for failing to achieve its goals. The whole project feels rushed, for a major initiative like this, with such ambitious goals.”

The primary “carrot” the initiative offers hospitals, Dr. Maynard notes, is access to patient safety improvement expertise and resources that they would otherwise have to purchase on their own, including training materials, implementation guides, webinars, and site visits by HEN representatives.

As an indirect inducement to participate, CMS’ Hospital Readmissions Reduction Program begins this October and will penalize hospitals by as much as 1% of their total Medicare billings (increasing to 3% in 2015) for high rates of readmissions related to heart attack, heart failure, and pneumonia. CMS’ Value-Based Purchasing program also continues to reward and punish hospitals for their performance on core measures and patient satisfaction, with more metrics forthcoming.

Metric Morass

A major challenge to the success of Partnership for Patients will be the ability to formulate and share reliable, uniform patient safety metrics across institutions. The initiative gives each of the 26 HENs the flexibility to tailor their activities to the sites they are mentoring, and there is no clear way of making standardized comparisons of hospital performance across the HENs, Dr. Maynard says.

Metric validity is a crucial component of any QI initiative. And yet, the ability to reliably measure patient harm/adverse event rates at hospitals—and therefore achieving a solid “denominator” baseline with which to track progress—remains elusive. In a recent report, the U.S. Department of Health and Human Services’ Office of the Inspector General noted that hospital incident reporting systems capture only an estimated 14% of the patient harm events experienced by Medicare patients, reporting requirements remain unclear, and hospital staff continue to harbor misperceptions about what constitutes patient harm.²

In what almost sounds like “back to the drawing board,” the report recommended that CMS and the Agency for Healthcare Research and Quality (AHRQ) collaborate to create and promote a list of potentially reportable events for hospitals to use, and that CMS provide guidance to accreditors regarding their assessments of hospital efforts to track and analyze events.

The problem is that voluntary incident reporting systems are only one tool for identifying patient harm. Typically, however, they miss many things that can harm patients and are grossly under-reported. As a result, they need to be used in conjunction with other data sources, such as hospital infection rates, daily safety rounding on hospital units, and patient chart sampling, says Katharine Luther, RN, MPM, the Institute for Healthcare Improvement’s vice president of hospital portfolio planning and administration.

Another excellent surveillance instrument for capturing a count of possible harm events is a Global Trigger Tool, which samples patient charts to identify aberrant lab values, drug dosages, and other untoward events that might indicate harm, even though they might not easily be recognized as harmful by hospital staff, Luther says.

Warranted Optimism

Despite its aggressive timeline and inherent methodological challenges, Luther says the Partnership for Patients will galvanize and focus hospitals’ patient safety improvement efforts and provide a much-needed framework for implementation.

“We know of organizations that have greatly reduced the incidence of pressure ulcers, and have gone for a year or more with no cases of ventilator-associated pneumonia or central-line-associated bloodstream infection (CLABSI),” Luther says. “Exemplars like these are out there, so it can be done. Partnership for Patients brings a spotlight and an energy to the issue that will last long beyond the 24 months of this program.”

Chris Guadagnino is a freelance medical writer in Philadelphia.

References

1. CMS Fact Sheet. Hospital Engagement Networks: Connecting Hospitals to Improve Care. Centers for Medicare & Medicaid website. Available at: http://www.cms.gov/apps/media/press/factsheet.asp?Counter=4219&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date. Accessed Feb. 12, 2012.
2. HHS Office of Inspector General. Hospital Incident Reporting Systems Do Not Capture Most Patient Harm. Office of Inspector General website. Available at: http://oig.hhs.gov/oei/reports/oei-06-09-00091.pdf. Accessed Feb. 12, 2012.

Does your employer provide your medical malpractice insurance coverage? Are you looking for new employment? Are you in the market to purchase a professional malpractice insurance policy? Are you planning to retire soon?

If you answered “yes” to any of these questions, you likely will confront the concept of “tail” insurance at some point in your medical career.

Now is the time to dust off your employment agreement and professional liability insurance policy and review what happens in the event a lawsuit is filed against you after you leave your current employer. This means paying special attention to whether your professional liability insurance policy provides for claims-made or occurrence-based coverage, and, if it’s the former, who is responsible for purchasing tail coverage.

When Do I Need Tail Coverage?

Tail insurance issues frequently arise when a physician leaves his or her place of employment, whether due to switching jobs, retirement, or a buyout of a physician’s ownership interest. If the physician is leaving an employer that has claims-made professional liability insurance, the physician’s insurance coverage might not be seamless. Instead, tail or similar coverage is required.

Claims-made coverage protects a physician for professional negligence, as long as a two-part test is met: First, the physician must have the claims-made coverage in place when the negligent act occurs (with employer No. 1); second, the physician must be covered by the same carrier when he or she is notified of the claim while employed by employer No. 2. If either test is not satisfied, the current claims-made insurance policy will not provide coverage to the physician in the event a lawsuit is filed for an act of negligence that took place while employed by employer No. 1. Alternatively, some employers offer “nose” coverage from its insurance carrier, which will cover negligent acts that might have occurred during your current job. The vast majority of professional liability insurance policies written for medical practice groups are for claims-made coverage.

If, however, an employer has occurrence-based professional liability insurance, the departing physician’s insurance coverage is seamless and no tail insurance is required.

Example A

Here is a common example of what happens when a physician leaves an employer with claims-made professional liability coverage:

An employer maintains claims-made professional liability insurance coverage for its physicians with ABC Insurance Co. A physician decides to leave his or her current employer and accepts employment by a new employer, which maintains claims-made coverage with XYZ Insurance Co.

Within a few months of the physician’s new employment, a medical malpractice lawsuit is filed by a patient for medical treatment the patient received when the physician was employed by the former employer. By leaving the former employer, the departing physician automatically fails the two-part test for claims-made coverage, as the second prong is not satisfied. Therefore, even though the physician has liability coverage through the new employer, this insurance policy will not cover the lawsuit described above.

Unless the physician has tail insurance (or nose coverage) to cover lawsuits related to the former employment, a gap in liability coverage will exist. If claims-made insurance is the benefit you have received in your employment agreement, it is imperative that you understand that tail coverage is necessary when you leave.

However, if a physician leaves and a) is subsequently employed within the same state and b) stays insured by the same insurance carrier, then the insurance carrier will provide continuous coverage and no tail insurance policy is needed.

Who Pays the Premium?

If the physician will need tail coverage, the next critical question is, Who pays for such coverage? Even though tail coverage comes into effect when a physician leaves an employer, tail coverage should be addressed before the physician informs the employer of their departure; an even better approach would be while the employment agreement is negotiated. Payment of tail coverage should be defined in the physician’s employment agreement.

In terms of payment for the coverage, there are several options. First, the cost of tail coverage can be attributed 100% to either physician or employer. In specialties for which recruitment of new physicians is challenging (i.e. HM), employers are more likely to pay a substantial portion, if not all, of the cost as a benefit or inducement.

Second, the physician can connect the payment of tail coverage to the manner in which employment is terminated. For example, if the physician terminates the agreement for cause or if the employer terminates the physician’s employment without cause, the employer could be required to pay for the tail insurance. Alternatively, if the physician terminates the agreement without cause or if the employer terminates the physician’s employment with cause, the physician could be required to pay for the tail coverage. Frequently, physician employment agreements require physicians to pay for tail coverage if the physician violates a restrictive covenant (e.g. non-competition).

A third option is to split the cost of tail insurance between the former employer and the physician based on a percentage, or to include a vesting schedule, for example, such that the former employer pays one-third of the coverage if employment ends in the second year, two-thirds of the coverage if employment ends in the third year, and 100% of the coverage if employment ends in the fourth year or later.

Whatever arrangement the parties agree upon should be included in the physician’s employment agreement in order to prevent an expensive surprise.

Review Your Policy

Now that you have an understanding of claims-made coverage, occurrence-based coverage and tail insurance, it’s time to review your insurance policy. When reviewing your current policy, look for answers to the following important questions:

• Is your policy claims-made or occurrence-based?
• Does your insurance policy only cover professional negligence claims? Does your policy also cover claims of unprofessional conduct reported to state medical licensing boards? Does your policy also cover medical staff bylaw disputes and state licensing matters?
• How is loss defined? “Pure loss” is coverage for the amount awarded to the plaintiff; “ultimate net loss” covers what pure loss covers, plus attorneys’ fees and costs.
• What procedures do you need to follow in order to properly notify the insurance carrier of a claim? Are you precluded from full coverage if you fail to properly report?
• What does the “duty to defend” provision cover? Will you be reimbursed for lost wages for your time in court? What services will be provided as part of your defense?
• What does the “consent to settle” provision say? If a settlement is negotiated between the plaintiff (patient) and the insurance company and the physician does not consent to the settlement, is the physician responsible for the ongoing defense costs and the amount of any verdict in excess of the recommended settlement amount?

It is important to both understand your insurance policy and what your employment agreement says about the policy. If you will be responsible for purchasing a tail policy at the end of your current employment, you should be well aware—and financially prepared—for this post-employment responsibility. Make sure your tail is not left exposed.

Steven M. Harris, Esq., is a nationally recognized healthcare attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at sharris@mcdonaldhopkins.com.

Does your employer provide your medical malpractice insurance coverage? Are you looking for new employment? Are you in the market to purchase a professional malpractice insurance policy? Are you planning to retire soon?

If you answered “yes” to any of these questions, you likely will confront the concept of “tail” insurance at some point in your medical career.

Now is the time to dust off your employment agreement and professional liability insurance policy and review what happens in the event a lawsuit is filed against you after you leave your current employer. This means paying special attention to whether your professional liability insurance policy provides for claims-made or occurrence-based coverage, and, if it’s the former, who is responsible for purchasing tail coverage.

When Do I Need Tail Coverage?

Tail insurance issues frequently arise when a physician leaves his or her place of employment, whether due to switching jobs, retirement, or a buyout of a physician’s ownership interest. If the physician is leaving an employer that has claims-made professional liability insurance, the physician’s insurance coverage might not be seamless. Instead, tail or similar coverage is required.

Claims-made coverage protects a physician for professional negligence, as long as a two-part test is met: First, the physician must have the claims-made coverage in place when the negligent act occurs (with employer No. 1); second, the physician must be covered by the same carrier when he or she is notified of the claim while employed by employer No. 2. If either test is not satisfied, the current claims-made insurance policy will not provide coverage to the physician in the event a lawsuit is filed for an act of negligence that took place while employed by employer No. 1. Alternatively, some employers offer “nose” coverage from its insurance carrier, which will cover negligent acts that might have occurred during your current job. The vast majority of professional liability insurance policies written for medical practice groups are for claims-made coverage.

If, however, an employer has occurrence-based professional liability insurance, the departing physician’s insurance coverage is seamless and no tail insurance is required.

Example A

Here is a common example of what happens when a physician leaves an employer with claims-made professional liability coverage:

An employer maintains claims-made professional liability insurance coverage for its physicians with ABC Insurance Co. A physician decides to leave his or her current employer and accepts employment by a new employer, which maintains claims-made coverage with XYZ Insurance Co.

Within a few months of the physician’s new employment, a medical malpractice lawsuit is filed by a patient for medical treatment the patient received when the physician was employed by the former employer. By leaving the former employer, the departing physician automatically fails the two-part test for claims-made coverage, as the second prong is not satisfied. Therefore, even though the physician has liability coverage through the new employer, this insurance policy will not cover the lawsuit described above.

Unless the physician has tail insurance (or nose coverage) to cover lawsuits related to the former employment, a gap in liability coverage will exist. If claims-made insurance is the benefit you have received in your employment agreement, it is imperative that you understand that tail coverage is necessary when you leave.

However, if a physician leaves and a) is subsequently employed within the same state and b) stays insured by the same insurance carrier, then the insurance carrier will provide continuous coverage and no tail insurance policy is needed.

Who Pays the Premium?

If the physician will need tail coverage, the next critical question is, Who pays for such coverage? Even though tail coverage comes into effect when a physician leaves an employer, tail coverage should be addressed before the physician informs the employer of their departure; an even better approach would be while the employment agreement is negotiated. Payment of tail coverage should be defined in the physician’s employment agreement.

In terms of payment for the coverage, there are several options. First, the cost of tail coverage can be attributed 100% to either physician or employer. In specialties for which recruitment of new physicians is challenging (i.e. HM), employers are more likely to pay a substantial portion, if not all, of the cost as a benefit or inducement.

Second, the physician can connect the payment of tail coverage to the manner in which employment is terminated. For example, if the physician terminates the agreement for cause or if the employer terminates the physician’s employment without cause, the employer could be required to pay for the tail insurance. Alternatively, if the physician terminates the agreement without cause or if the employer terminates the physician’s employment with cause, the physician could be required to pay for the tail coverage. Frequently, physician employment agreements require physicians to pay for tail coverage if the physician violates a restrictive covenant (e.g. non-competition).

A third option is to split the cost of tail insurance between the former employer and the physician based on a percentage, or to include a vesting schedule, for example, such that the former employer pays one-third of the coverage if employment ends in the second year, two-thirds of the coverage if employment ends in the third year, and 100% of the coverage if employment ends in the fourth year or later.

Whatever arrangement the parties agree upon should be included in the physician’s employment agreement in order to prevent an expensive surprise.

Review Your Policy

Now that you have an understanding of claims-made coverage, occurrence-based coverage and tail insurance, it’s time to review your insurance policy. When reviewing your current policy, look for answers to the following important questions:

• Is your policy claims-made or occurrence-based?
• Does your insurance policy only cover professional negligence claims? Does your policy also cover claims of unprofessional conduct reported to state medical licensing boards? Does your policy also cover medical staff bylaw disputes and state licensing matters?
• How is loss defined? “Pure loss” is coverage for the amount awarded to the plaintiff; “ultimate net loss” covers what pure loss covers, plus attorneys’ fees and costs.
• What procedures do you need to follow in order to properly notify the insurance carrier of a claim? Are you precluded from full coverage if you fail to properly report?
• What does the “duty to defend” provision cover? Will you be reimbursed for lost wages for your time in court? What services will be provided as part of your defense?
• What does the “consent to settle” provision say? If a settlement is negotiated between the plaintiff (patient) and the insurance company and the physician does not consent to the settlement, is the physician responsible for the ongoing defense costs and the amount of any verdict in excess of the recommended settlement amount?

It is important to both understand your insurance policy and what your employment agreement says about the policy. If you will be responsible for purchasing a tail policy at the end of your current employment, you should be well aware—and financially prepared—for this post-employment responsibility. Make sure your tail is not left exposed.

Steven M. Harris, Esq., is a nationally recognized healthcare attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at sharris@mcdonaldhopkins.com.

Does your employer provide your medical malpractice insurance coverage? Are you looking for new employment? Are you in the market to purchase a professional malpractice insurance policy? Are you planning to retire soon?

If you answered “yes” to any of these questions, you likely will confront the concept of “tail” insurance at some point in your medical career.

Now is the time to dust off your employment agreement and professional liability insurance policy and review what happens in the event a lawsuit is filed against you after you leave your current employer. This means paying special attention to whether your professional liability insurance policy provides for claims-made or occurrence-based coverage, and, if it’s the former, who is responsible for purchasing tail coverage.

When Do I Need Tail Coverage?

Tail insurance issues frequently arise when a physician leaves his or her place of employment, whether due to switching jobs, retirement, or a buyout of a physician’s ownership interest. If the physician is leaving an employer that has claims-made professional liability insurance, the physician’s insurance coverage might not be seamless. Instead, tail or similar coverage is required.

Claims-made coverage protects a physician for professional negligence, as long as a two-part test is met: First, the physician must have the claims-made coverage in place when the negligent act occurs (with employer No. 1); second, the physician must be covered by the same carrier when he or she is notified of the claim while employed by employer No. 2. If either test is not satisfied, the current claims-made insurance policy will not provide coverage to the physician in the event a lawsuit is filed for an act of negligence that took place while employed by employer No. 1. Alternatively, some employers offer “nose” coverage from its insurance carrier, which will cover negligent acts that might have occurred during your current job. The vast majority of professional liability insurance policies written for medical practice groups are for claims-made coverage.

If, however, an employer has occurrence-based professional liability insurance, the departing physician’s insurance coverage is seamless and no tail insurance is required.

Example A

Here is a common example of what happens when a physician leaves an employer with claims-made professional liability coverage:

An employer maintains claims-made professional liability insurance coverage for its physicians with ABC Insurance Co. A physician decides to leave his or her current employer and accepts employment by a new employer, which maintains claims-made coverage with XYZ Insurance Co.

Within a few months of the physician’s new employment, a medical malpractice lawsuit is filed by a patient for medical treatment the patient received when the physician was employed by the former employer. By leaving the former employer, the departing physician automatically fails the two-part test for claims-made coverage, as the second prong is not satisfied. Therefore, even though the physician has liability coverage through the new employer, this insurance policy will not cover the lawsuit described above.

Unless the physician has tail insurance (or nose coverage) to cover lawsuits related to the former employment, a gap in liability coverage will exist. If claims-made insurance is the benefit you have received in your employment agreement, it is imperative that you understand that tail coverage is necessary when you leave.

However, if a physician leaves and a) is subsequently employed within the same state and b) stays insured by the same insurance carrier, then the insurance carrier will provide continuous coverage and no tail insurance policy is needed.

Who Pays the Premium?

If the physician will need tail coverage, the next critical question is, Who pays for such coverage? Even though tail coverage comes into effect when a physician leaves an employer, tail coverage should be addressed before the physician informs the employer of their departure; an even better approach would be while the employment agreement is negotiated. Payment of tail coverage should be defined in the physician’s employment agreement.

In terms of payment for the coverage, there are several options. First, the cost of tail coverage can be attributed 100% to either physician or employer. In specialties for which recruitment of new physicians is challenging (i.e. HM), employers are more likely to pay a substantial portion, if not all, of the cost as a benefit or inducement.

Second, the physician can connect the payment of tail coverage to the manner in which employment is terminated. For example, if the physician terminates the agreement for cause or if the employer terminates the physician’s employment without cause, the employer could be required to pay for the tail insurance. Alternatively, if the physician terminates the agreement without cause or if the employer terminates the physician’s employment with cause, the physician could be required to pay for the tail coverage. Frequently, physician employment agreements require physicians to pay for tail coverage if the physician violates a restrictive covenant (e.g. non-competition).

A third option is to split the cost of tail insurance between the former employer and the physician based on a percentage, or to include a vesting schedule, for example, such that the former employer pays one-third of the coverage if employment ends in the second year, two-thirds of the coverage if employment ends in the third year, and 100% of the coverage if employment ends in the fourth year or later.

Whatever arrangement the parties agree upon should be included in the physician’s employment agreement in order to prevent an expensive surprise.

Review Your Policy

Now that you have an understanding of claims-made coverage, occurrence-based coverage and tail insurance, it’s time to review your insurance policy. When reviewing your current policy, look for answers to the following important questions:

• Is your policy claims-made or occurrence-based?
• Does your insurance policy only cover professional negligence claims? Does your policy also cover claims of unprofessional conduct reported to state medical licensing boards? Does your policy also cover medical staff bylaw disputes and state licensing matters?
• How is loss defined? “Pure loss” is coverage for the amount awarded to the plaintiff; “ultimate net loss” covers what pure loss covers, plus attorneys’ fees and costs.
• What procedures do you need to follow in order to properly notify the insurance carrier of a claim? Are you precluded from full coverage if you fail to properly report?
• What does the “duty to defend” provision cover? Will you be reimbursed for lost wages for your time in court? What services will be provided as part of your defense?
• What does the “consent to settle” provision say? If a settlement is negotiated between the plaintiff (patient) and the insurance company and the physician does not consent to the settlement, is the physician responsible for the ongoing defense costs and the amount of any verdict in excess of the recommended settlement amount?

It is important to both understand your insurance policy and what your employment agreement says about the policy. If you will be responsible for purchasing a tail policy at the end of your current employment, you should be well aware—and financially prepared—for this post-employment responsibility. Make sure your tail is not left exposed.

Steven M. Harris, Esq., is a nationally recognized healthcare attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at sharris@mcdonaldhopkins.com.

In some ways, Femi Adewunmi, MD, MBA, CPE, SFHM, seemed destined to become a physician. He grew up in a medical family—his mother is an orthodontist; his father is an obstetrician/gynecologist. As a child, he often spent holidays visiting patients at the hospital where his dad worked. He grew to appreciate medicine as a noble profession, and when he reached his teens, he never seriously considered another career path.

“There were times when I was in medical school, dreading having to study for the numerous tests and exams, when I wished I had someone I could have blamed my decision to go to medical school on,” says Dr. Adewunmi, a native of Nigeria who has practiced as a hospitalist in the U.S. since 2003. “But no one pushed me to do it. It was something I always looked forward to doing, and I’m very glad I stuck with it.”

Dr. Adewunmi has only become more passionate about his work since then. His experience as a front-line hospitalist laid the foundation for a series of leadership roles, first directing the HM program at Johnston Memorial Hospital in Smithfield, N.C., and now as regional chief medical officer for Sound Physicians, which provides inpatient services to more than 70 hospitals nationally.

“I really want to be a good physician executive,” he says. “It’s definitely a case of ‘The more you learn, the more you realize how little you know.’ I still have a lot to learn, but I’m looking forward to the challenge.”

When did you decide to go into HM?

During residency, I realized I loved taking care of patients in the hospital, both along the wards and in the ICU. I enjoyed my outpatient clinics but found myself looking for any reason I could to stay in the hospital caring for patients. I was interested in patient safety and I was doing a little bit of utilization review, so I also felt it would give me a great overall perspective of the healthcare system.

What about leading the hospitalist program at Johnston Memorial appealed to you?

I enjoyed clinical medicine, and I still do, but I was looking to do more. I wanted to make an impact at a systems level, and I knew, to do that, I eventually had to gain some leadership experience.

What is the most valuable lesson you learned in that role?

Understanding that change doesn’t happen instantaneously. For instance, as a clinician, you sometimes admit patients with congestive heart failure. You diagnose correctly, treat appropriately, and in a few days, the patients do better and go home. You get pretty swift gratification. Administration is much different. You put processes in place and it could take weeks or several quarters before you start to see the effects of the changes you implement.

What appealed to you about moving from a single-site leadership position at Johnston to a regional position with Sound?

I wanted to continue evolving. I wanted more of a challenge and was seeking opportunities where I would have operational responsibility—overseeing performance improvement in quality, satisfaction, and financial performance for several programs. In addition, I wanted to be accountable for physician development, recruiting, negotiations, and the whole gamut of business development. It was the next logical step in my career.

Why did you pursue an MBA?

I’d made that decision just before I got into medical school. I recall first thinking about it after a conversation I had with my father as a teenager. When I told him that I had made up my mind to study medicine, he said, “You should consider getting an MBA as well. Your generation is going to need to have business experience and expertise, and be better in that area than our generation was.” It’s been invaluable for me in terms of preparing me for handling the business side of medicine, including ways to make operations more efficient and to reduce costs without compromising the quality of care provided.

You have worked in both hospital-employed and privately contracted HM programs. Do you prefer one model?

In general, the larger organizations tend to have an advantage in that they have established protocols and processes that work and have been refined over time. Couple that with the economies of scale they enjoy, as we move into an era of value-based purchasing, it’s becoming harder for the smaller community-based hospital to do that as well. That said, I have seen local hospital-run programs that function really well and have administrative support, so there is definitely enough room for both models.

You were in the inaugural FHM class. What did that recognition mean to you?

I saw it as validation of how we were starting to mature as a specialty and as recognition of a commitment to being a hospitalist, not just an internist. I never practiced outpatient medicine. I went straight from residency to hospitalist medicine. That’s how I identify myself, and I was happy to see that physicians specializing in hospital medicine were starting to get recognized.

What is your biggest professional reward?

The satisfaction from knowing you’re making a difference—not just by the care you provide one-on-one to your patients, but also knowing you’re contributing at a systems level or a population level because you’re making decisions and trying to redefine processes that actually could impact a much larger cohort.

What is your biggest professional challenge?

Trying to find enough hours in the day to do all that needs to be done.

What is next for you professionally?

I enjoy having varied opportunities and being involved in many different aspects of operations. That’s what attracted me to a larger company such as Sound Physicians, and I see myself staying in that type of role. Down the road, I’d love to be able to take some of my knowledge to Nigeria and find a way to help develop and shape the healthcare sector back home.

Why would that mean so much to you?

It would be a chance to give back. We still have people dying from largely preventable diseases, and our healthcare system is not what it should be. We don’t have enough physicians for the population, and most of the physicians are in urban areas.

Close to half of the members of my graduating medical school class are either in the U.S., Europe, Asia, or South Africa.

That type of brain drain has a tremendous effect over several decades. That’s a lot of talent outside the country, and we need that back home.

Mark Leiser is a freelance writer in New Jersey.

In some ways, Femi Adewunmi, MD, MBA, CPE, SFHM, seemed destined to become a physician. He grew up in a medical family—his mother is an orthodontist; his father is an obstetrician/gynecologist. As a child, he often spent holidays visiting patients at the hospital where his dad worked. He grew to appreciate medicine as a noble profession, and when he reached his teens, he never seriously considered another career path.

“There were times when I was in medical school, dreading having to study for the numerous tests and exams, when I wished I had someone I could have blamed my decision to go to medical school on,” says Dr. Adewunmi, a native of Nigeria who has practiced as a hospitalist in the U.S. since 2003. “But no one pushed me to do it. It was something I always looked forward to doing, and I’m very glad I stuck with it.”

Dr. Adewunmi has only become more passionate about his work since then. His experience as a front-line hospitalist laid the foundation for a series of leadership roles, first directing the HM program at Johnston Memorial Hospital in Smithfield, N.C., and now as regional chief medical officer for Sound Physicians, which provides inpatient services to more than 70 hospitals nationally.

“I really want to be a good physician executive,” he says. “It’s definitely a case of ‘The more you learn, the more you realize how little you know.’ I still have a lot to learn, but I’m looking forward to the challenge.”

When did you decide to go into HM?

During residency, I realized I loved taking care of patients in the hospital, both along the wards and in the ICU. I enjoyed my outpatient clinics but found myself looking for any reason I could to stay in the hospital caring for patients. I was interested in patient safety and I was doing a little bit of utilization review, so I also felt it would give me a great overall perspective of the healthcare system.

What about leading the hospitalist program at Johnston Memorial appealed to you?

I enjoyed clinical medicine, and I still do, but I was looking to do more. I wanted to make an impact at a systems level, and I knew, to do that, I eventually had to gain some leadership experience.

What is the most valuable lesson you learned in that role?

Understanding that change doesn’t happen instantaneously. For instance, as a clinician, you sometimes admit patients with congestive heart failure. You diagnose correctly, treat appropriately, and in a few days, the patients do better and go home. You get pretty swift gratification. Administration is much different. You put processes in place and it could take weeks or several quarters before you start to see the effects of the changes you implement.

What appealed to you about moving from a single-site leadership position at Johnston to a regional position with Sound?

I wanted to continue evolving. I wanted more of a challenge and was seeking opportunities where I would have operational responsibility—overseeing performance improvement in quality, satisfaction, and financial performance for several programs. In addition, I wanted to be accountable for physician development, recruiting, negotiations, and the whole gamut of business development. It was the next logical step in my career.

Why did you pursue an MBA?

I’d made that decision just before I got into medical school. I recall first thinking about it after a conversation I had with my father as a teenager. When I told him that I had made up my mind to study medicine, he said, “You should consider getting an MBA as well. Your generation is going to need to have business experience and expertise, and be better in that area than our generation was.” It’s been invaluable for me in terms of preparing me for handling the business side of medicine, including ways to make operations more efficient and to reduce costs without compromising the quality of care provided.

You have worked in both hospital-employed and privately contracted HM programs. Do you prefer one model?

In general, the larger organizations tend to have an advantage in that they have established protocols and processes that work and have been refined over time. Couple that with the economies of scale they enjoy, as we move into an era of value-based purchasing, it’s becoming harder for the smaller community-based hospital to do that as well. That said, I have seen local hospital-run programs that function really well and have administrative support, so there is definitely enough room for both models.

You were in the inaugural FHM class. What did that recognition mean to you?

I saw it as validation of how we were starting to mature as a specialty and as recognition of a commitment to being a hospitalist, not just an internist. I never practiced outpatient medicine. I went straight from residency to hospitalist medicine. That’s how I identify myself, and I was happy to see that physicians specializing in hospital medicine were starting to get recognized.

What is your biggest professional reward?

The satisfaction from knowing you’re making a difference—not just by the care you provide one-on-one to your patients, but also knowing you’re contributing at a systems level or a population level because you’re making decisions and trying to redefine processes that actually could impact a much larger cohort.

What is your biggest professional challenge?

Trying to find enough hours in the day to do all that needs to be done.

What is next for you professionally?

I enjoy having varied opportunities and being involved in many different aspects of operations. That’s what attracted me to a larger company such as Sound Physicians, and I see myself staying in that type of role. Down the road, I’d love to be able to take some of my knowledge to Nigeria and find a way to help develop and shape the healthcare sector back home.

Why would that mean so much to you?

It would be a chance to give back. We still have people dying from largely preventable diseases, and our healthcare system is not what it should be. We don’t have enough physicians for the population, and most of the physicians are in urban areas.

Close to half of the members of my graduating medical school class are either in the U.S., Europe, Asia, or South Africa.

That type of brain drain has a tremendous effect over several decades. That’s a lot of talent outside the country, and we need that back home.

Mark Leiser is a freelance writer in New Jersey.

In some ways, Femi Adewunmi, MD, MBA, CPE, SFHM, seemed destined to become a physician. He grew up in a medical family—his mother is an orthodontist; his father is an obstetrician/gynecologist. As a child, he often spent holidays visiting patients at the hospital where his dad worked. He grew to appreciate medicine as a noble profession, and when he reached his teens, he never seriously considered another career path.

“There were times when I was in medical school, dreading having to study for the numerous tests and exams, when I wished I had someone I could have blamed my decision to go to medical school on,” says Dr. Adewunmi, a native of Nigeria who has practiced as a hospitalist in the U.S. since 2003. “But no one pushed me to do it. It was something I always looked forward to doing, and I’m very glad I stuck with it.”

Dr. Adewunmi has only become more passionate about his work since then. His experience as a front-line hospitalist laid the foundation for a series of leadership roles, first directing the HM program at Johnston Memorial Hospital in Smithfield, N.C., and now as regional chief medical officer for Sound Physicians, which provides inpatient services to more than 70 hospitals nationally.

“I really want to be a good physician executive,” he says. “It’s definitely a case of ‘The more you learn, the more you realize how little you know.’ I still have a lot to learn, but I’m looking forward to the challenge.”

When did you decide to go into HM?

During residency, I realized I loved taking care of patients in the hospital, both along the wards and in the ICU. I enjoyed my outpatient clinics but found myself looking for any reason I could to stay in the hospital caring for patients. I was interested in patient safety and I was doing a little bit of utilization review, so I also felt it would give me a great overall perspective of the healthcare system.

What about leading the hospitalist program at Johnston Memorial appealed to you?

I enjoyed clinical medicine, and I still do, but I was looking to do more. I wanted to make an impact at a systems level, and I knew, to do that, I eventually had to gain some leadership experience.

What is the most valuable lesson you learned in that role?

Understanding that change doesn’t happen instantaneously. For instance, as a clinician, you sometimes admit patients with congestive heart failure. You diagnose correctly, treat appropriately, and in a few days, the patients do better and go home. You get pretty swift gratification. Administration is much different. You put processes in place and it could take weeks or several quarters before you start to see the effects of the changes you implement.

What appealed to you about moving from a single-site leadership position at Johnston to a regional position with Sound?

I wanted to continue evolving. I wanted more of a challenge and was seeking opportunities where I would have operational responsibility—overseeing performance improvement in quality, satisfaction, and financial performance for several programs. In addition, I wanted to be accountable for physician development, recruiting, negotiations, and the whole gamut of business development. It was the next logical step in my career.

Why did you pursue an MBA?

I’d made that decision just before I got into medical school. I recall first thinking about it after a conversation I had with my father as a teenager. When I told him that I had made up my mind to study medicine, he said, “You should consider getting an MBA as well. Your generation is going to need to have business experience and expertise, and be better in that area than our generation was.” It’s been invaluable for me in terms of preparing me for handling the business side of medicine, including ways to make operations more efficient and to reduce costs without compromising the quality of care provided.

You have worked in both hospital-employed and privately contracted HM programs. Do you prefer one model?

In general, the larger organizations tend to have an advantage in that they have established protocols and processes that work and have been refined over time. Couple that with the economies of scale they enjoy, as we move into an era of value-based purchasing, it’s becoming harder for the smaller community-based hospital to do that as well. That said, I have seen local hospital-run programs that function really well and have administrative support, so there is definitely enough room for both models.

You were in the inaugural FHM class. What did that recognition mean to you?

I saw it as validation of how we were starting to mature as a specialty and as recognition of a commitment to being a hospitalist, not just an internist. I never practiced outpatient medicine. I went straight from residency to hospitalist medicine. That’s how I identify myself, and I was happy to see that physicians specializing in hospital medicine were starting to get recognized.

What is your biggest professional reward?

The satisfaction from knowing you’re making a difference—not just by the care you provide one-on-one to your patients, but also knowing you’re contributing at a systems level or a population level because you’re making decisions and trying to redefine processes that actually could impact a much larger cohort.

What is your biggest professional challenge?

Trying to find enough hours in the day to do all that needs to be done.

What is next for you professionally?

I enjoy having varied opportunities and being involved in many different aspects of operations. That’s what attracted me to a larger company such as Sound Physicians, and I see myself staying in that type of role. Down the road, I’d love to be able to take some of my knowledge to Nigeria and find a way to help develop and shape the healthcare sector back home.

Why would that mean so much to you?

It would be a chance to give back. We still have people dying from largely preventable diseases, and our healthcare system is not what it should be. We don’t have enough physicians for the population, and most of the physicians are in urban areas.

Close to half of the members of my graduating medical school class are either in the U.S., Europe, Asia, or South Africa.

That type of brain drain has a tremendous effect over several decades. That’s a lot of talent outside the country, and we need that back home.

Mark Leiser is a freelance writer in New Jersey.

Providers typically rely on the “key components” (history, exam, medical decision-making) when documenting in the medical record. However, there are instances when the majority of the encounter constitutes counseling/coordination of care (C/CC). Physicians might only document a brief history and exam, or nothing at all. Utilizing time-based billing principles allows a physician to disregard the “key component” requirements and select a visit level reflective of this effort.

For example, a 64-year-old female is hospitalized with newly diagnosed diabetes and requires extensive counseling regarding disease management, lifestyle modification, and medication regime, as well as coordination of care for outpatient programs and services. The hospitalist reviews some of the pertinent information with the patient and leaves the room to coordinate the patient’s ongoing care (25 minutes). The hospitalist then asks a resident to assist with the remaining counseling efforts (20 minutes). Code 99232 (inpatient visit, 25 minutes total visit time) would be appropriate to report.

Counseling, Coordination of Care

Time may be used as the determining factor for the visit level, if more than 50% of the total visit time involves C/CC.¹ Time is not used for visit-level selection if C/CC is minimal or absent from the patient encounter. Total visit time is acknowledged as the physician’s face-to-face (i.e. bedside) time combined with time spent on the unit/floor reviewing data, obtaining relevant patient information, and discussing the individual case with other involved healthcare providers.

Time associated with activities performed outside of the patient’s unit/floor is not considered when calculating total visit time. Time associated with teaching students/interns also is excluded; only the attending physician’s time counts.

When the requirements have been met, the physician selects the visit level that corresponds with the documented total visit time (see Table 1). In the scenario above, the visit level is chosen based on the attending physician’s documented time (25 minutes). The resident’s time cannot be included.

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Documentation Requirements

Physicians must document the interaction during the patient encounter: history and exam, if updated or performed; discussion points; and patient response, if applicable. The medical record entry must contain both the C/CC time and the total visit time.² “Total visit time=35 minutes; >50% spent counseling/coordinating care” or “20 of 35 minutes spent counseling/coordinating care.”

A payor may prefer one documentation style over another. It is always best to ask about the payor’s policy and review local documentation standards to ensure compliance.

Family Discussions

Physicians are always involved in family discussions. It is appropriate to count this as C/CC time. In the event that the family discussion takes place without the patient present, only count this as C/CC time if:

• The patient is unable or clinically incompetent to participate in discussions;
• The time is spent on the unit/floor with the family members or surrogate decision-makers obtaining a medical history, reviewing the patient’s condition or prognosis, or discussing treatment or limitation(s) of treatment; and
• The conversation bears directly on the management of the patient.⁴

The medical record should reflect these criteria. Do not consider the time if the discussion takes place in an area outside of the patient’s unit/floor, or if the time is spent counseling family members through their grieving process.

It is not uncommon for the family discussion to take place later in the day, after the physician has made earlier rounds. If the earlier encounter involved C/CC, the physician would report the cumulative time spent for that service date. If the earlier encounter was a typical patient evaluation (i.e. history update and physical) and management service (i.e. care plan review/revision), this second encounter might be regarded as a prolonged care service.

Prolonged Care

Prolonged care codes exist for both outpatient and inpatient services. A hospitalists’ focus involves the inpatient code series:

99356: Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service, first hour; and

99357: Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service, each additional 30 minutes.

click for large version

Code 99356 is reported during the first hour of prolonged services, after the initial 30 minutes is reached; code 99357 is reported for each additional 30 minutes of prolonged care beyond the first hour, after the first 15 minutes of each additional segment. Both are “add on” codes and cannot be reported alone on a claim form; a “primary” code must be reported. Similarly, 99357 cannot be reported without 99356, and 99356 must be reported with one of the following inpatient service (primary) codes: 99218-99220, 99221-99223, 99231-99233, 99251-99255, 99304-99310. Only one unit of 99356 may be reported per patient per physician group per day, whereas multiple units of 99357 may be reported in a single day.

The CPT definition of prolonged care varies from that of the Centers for Medicare & Medicaid Services (CMS). Since 2009, CPT recognizes the total duration spent by a physician on a given date, even if the time spent by the physician on that date is not continuous; the time involves both face-to-face time and unit/floor time.⁵ CMS only attributes direct face-to-face time between the physician and the patient toward prolonged care billing. Time spent reviewing charts or discussion of a patient with house medical staff, waiting for test results, waiting for changes in the patient’s condition, waiting for end of a therapy session, or waiting for use of facilities cannot be billed as prolonged services.5 This is in direct opposition to its policy for C/CC services, and makes prolonged care services inefficient.

Medicare also identifies “threshold” time (see Table 2). The total physician visit time must exceed the time requirements associated with the “primary” codes by a 30-minute threshold (e.g. 99221+99356=30 minutes+30 minutes=60 minutes threshold time). The physician must document the total face-to-face time spent in separate notes throughout the day or, more realistically, in one cumulative note.

When two providers from the same group and same specialty perform services on the same date (e.g. physician A saw the patient during morning rounds, and physician B spoke with the patient/family in the afternoon), only one physician can report the cumulative service.⁶ As always, query payors for coverage, because some non-Medicare insurers do not recognize these codes.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual: Chapter 12, Section 30.6.1B. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 8, 2012.
2. Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual: Chapter 12, Section 30.6.1C. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 8, 2012.
3. Centers for Medicare & Medicaid Services (CMS). Medicare National Coverage Determinations Manual: Chapter 1, Section 70.1. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/manuals/downloads/ncd103c1_Part1.pdf. Accessed Jan. 8, 2012.
4. Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual: Chapter 12, Section 30.6.15.1C. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 8, 2012.
5. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011:7-21.
6. Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual: Chapter 12, Section 30.6.5. Centers for Medicare & Medicaid Services website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 8, 2012.

Providers typically rely on the “key components” (history, exam, medical decision-making) when documenting in the medical record. However, there are instances when the majority of the encounter constitutes counseling/coordination of care (C/CC). Physicians might only document a brief history and exam, or nothing at all. Utilizing time-based billing principles allows a physician to disregard the “key component” requirements and select a visit level reflective of this effort.

For example, a 64-year-old female is hospitalized with newly diagnosed diabetes and requires extensive counseling regarding disease management, lifestyle modification, and medication regime, as well as coordination of care for outpatient programs and services. The hospitalist reviews some of the pertinent information with the patient and leaves the room to coordinate the patient’s ongoing care (25 minutes). The hospitalist then asks a resident to assist with the remaining counseling efforts (20 minutes). Code 99232 (inpatient visit, 25 minutes total visit time) would be appropriate to report.

Counseling, Coordination of Care

Time may be used as the determining factor for the visit level, if more than 50% of the total visit time involves C/CC.¹ Time is not used for visit-level selection if C/CC is minimal or absent from the patient encounter. Total visit time is acknowledged as the physician’s face-to-face (i.e. bedside) time combined with time spent on the unit/floor reviewing data, obtaining relevant patient information, and discussing the individual case with other involved healthcare providers.

Time associated with activities performed outside of the patient’s unit/floor is not considered when calculating total visit time. Time associated with teaching students/interns also is excluded; only the attending physician’s time counts.

When the requirements have been met, the physician selects the visit level that corresponds with the documented total visit time (see Table 1). In the scenario above, the visit level is chosen based on the attending physician’s documented time (25 minutes). The resident’s time cannot be included.

click for large version

Documentation Requirements

Physicians must document the interaction during the patient encounter: history and exam, if updated or performed; discussion points; and patient response, if applicable. The medical record entry must contain both the C/CC time and the total visit time.² “Total visit time=35 minutes; >50% spent counseling/coordinating care” or “20 of 35 minutes spent counseling/coordinating care.”

A payor may prefer one documentation style over another. It is always best to ask about the payor’s policy and review local documentation standards to ensure compliance.

Family Discussions

Physicians are always involved in family discussions. It is appropriate to count this as C/CC time. In the event that the family discussion takes place without the patient present, only count this as C/CC time if:

• The patient is unable or clinically incompetent to participate in discussions;
• The time is spent on the unit/floor with the family members or surrogate decision-makers obtaining a medical history, reviewing the patient’s condition or prognosis, or discussing treatment or limitation(s) of treatment; and
• The conversation bears directly on the management of the patient.⁴

The medical record should reflect these criteria. Do not consider the time if the discussion takes place in an area outside of the patient’s unit/floor, or if the time is spent counseling family members through their grieving process.

It is not uncommon for the family discussion to take place later in the day, after the physician has made earlier rounds. If the earlier encounter involved C/CC, the physician would report the cumulative time spent for that service date. If the earlier encounter was a typical patient evaluation (i.e. history update and physical) and management service (i.e. care plan review/revision), this second encounter might be regarded as a prolonged care service.

Prolonged Care

Prolonged care codes exist for both outpatient and inpatient services. A hospitalists’ focus involves the inpatient code series:

99356: Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service, first hour; and

99357: Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service, each additional 30 minutes.

click for large version

Code 99356 is reported during the first hour of prolonged services, after the initial 30 minutes is reached; code 99357 is reported for each additional 30 minutes of prolonged care beyond the first hour, after the first 15 minutes of each additional segment. Both are “add on” codes and cannot be reported alone on a claim form; a “primary” code must be reported. Similarly, 99357 cannot be reported without 99356, and 99356 must be reported with one of the following inpatient service (primary) codes: 99218-99220, 99221-99223, 99231-99233, 99251-99255, 99304-99310. Only one unit of 99356 may be reported per patient per physician group per day, whereas multiple units of 99357 may be reported in a single day.

The CPT definition of prolonged care varies from that of the Centers for Medicare & Medicaid Services (CMS). Since 2009, CPT recognizes the total duration spent by a physician on a given date, even if the time spent by the physician on that date is not continuous; the time involves both face-to-face time and unit/floor time.⁵ CMS only attributes direct face-to-face time between the physician and the patient toward prolonged care billing. Time spent reviewing charts or discussion of a patient with house medical staff, waiting for test results, waiting for changes in the patient’s condition, waiting for end of a therapy session, or waiting for use of facilities cannot be billed as prolonged services.5 This is in direct opposition to its policy for C/CC services, and makes prolonged care services inefficient.

Medicare also identifies “threshold” time (see Table 2). The total physician visit time must exceed the time requirements associated with the “primary” codes by a 30-minute threshold (e.g. 99221+99356=30 minutes+30 minutes=60 minutes threshold time). The physician must document the total face-to-face time spent in separate notes throughout the day or, more realistically, in one cumulative note.

When two providers from the same group and same specialty perform services on the same date (e.g. physician A saw the patient during morning rounds, and physician B spoke with the patient/family in the afternoon), only one physician can report the cumulative service.⁶ As always, query payors for coverage, because some non-Medicare insurers do not recognize these codes.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual: Chapter 12, Section 30.6.1B. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 8, 2012.
2. Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual: Chapter 12, Section 30.6.1C. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 8, 2012.
3. Centers for Medicare & Medicaid Services (CMS). Medicare National Coverage Determinations Manual: Chapter 1, Section 70.1. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/manuals/downloads/ncd103c1_Part1.pdf. Accessed Jan. 8, 2012.
4. Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual: Chapter 12, Section 30.6.15.1C. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 8, 2012.
5. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011:7-21.
6. Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual: Chapter 12, Section 30.6.5. Centers for Medicare & Medicaid Services website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 8, 2012.

Providers typically rely on the “key components” (history, exam, medical decision-making) when documenting in the medical record. However, there are instances when the majority of the encounter constitutes counseling/coordination of care (C/CC). Physicians might only document a brief history and exam, or nothing at all. Utilizing time-based billing principles allows a physician to disregard the “key component” requirements and select a visit level reflective of this effort.

For example, a 64-year-old female is hospitalized with newly diagnosed diabetes and requires extensive counseling regarding disease management, lifestyle modification, and medication regime, as well as coordination of care for outpatient programs and services. The hospitalist reviews some of the pertinent information with the patient and leaves the room to coordinate the patient’s ongoing care (25 minutes). The hospitalist then asks a resident to assist with the remaining counseling efforts (20 minutes). Code 99232 (inpatient visit, 25 minutes total visit time) would be appropriate to report.

Counseling, Coordination of Care

Time may be used as the determining factor for the visit level, if more than 50% of the total visit time involves C/CC.¹ Time is not used for visit-level selection if C/CC is minimal or absent from the patient encounter. Total visit time is acknowledged as the physician’s face-to-face (i.e. bedside) time combined with time spent on the unit/floor reviewing data, obtaining relevant patient information, and discussing the individual case with other involved healthcare providers.

Time associated with activities performed outside of the patient’s unit/floor is not considered when calculating total visit time. Time associated with teaching students/interns also is excluded; only the attending physician’s time counts.

When the requirements have been met, the physician selects the visit level that corresponds with the documented total visit time (see Table 1). In the scenario above, the visit level is chosen based on the attending physician’s documented time (25 minutes). The resident’s time cannot be included.

click for large version

Documentation Requirements

Physicians must document the interaction during the patient encounter: history and exam, if updated or performed; discussion points; and patient response, if applicable. The medical record entry must contain both the C/CC time and the total visit time.² “Total visit time=35 minutes; >50% spent counseling/coordinating care” or “20 of 35 minutes spent counseling/coordinating care.”

A payor may prefer one documentation style over another. It is always best to ask about the payor’s policy and review local documentation standards to ensure compliance.

Family Discussions

Physicians are always involved in family discussions. It is appropriate to count this as C/CC time. In the event that the family discussion takes place without the patient present, only count this as C/CC time if:

• The patient is unable or clinically incompetent to participate in discussions;
• The time is spent on the unit/floor with the family members or surrogate decision-makers obtaining a medical history, reviewing the patient’s condition or prognosis, or discussing treatment or limitation(s) of treatment; and
• The conversation bears directly on the management of the patient.⁴

The medical record should reflect these criteria. Do not consider the time if the discussion takes place in an area outside of the patient’s unit/floor, or if the time is spent counseling family members through their grieving process.

It is not uncommon for the family discussion to take place later in the day, after the physician has made earlier rounds. If the earlier encounter involved C/CC, the physician would report the cumulative time spent for that service date. If the earlier encounter was a typical patient evaluation (i.e. history update and physical) and management service (i.e. care plan review/revision), this second encounter might be regarded as a prolonged care service.

Prolonged Care

Prolonged care codes exist for both outpatient and inpatient services. A hospitalists’ focus involves the inpatient code series:

99356: Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service, first hour; and

99357: Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service, each additional 30 minutes.

click for large version

Code 99356 is reported during the first hour of prolonged services, after the initial 30 minutes is reached; code 99357 is reported for each additional 30 minutes of prolonged care beyond the first hour, after the first 15 minutes of each additional segment. Both are “add on” codes and cannot be reported alone on a claim form; a “primary” code must be reported. Similarly, 99357 cannot be reported without 99356, and 99356 must be reported with one of the following inpatient service (primary) codes: 99218-99220, 99221-99223, 99231-99233, 99251-99255, 99304-99310. Only one unit of 99356 may be reported per patient per physician group per day, whereas multiple units of 99357 may be reported in a single day.

The CPT definition of prolonged care varies from that of the Centers for Medicare & Medicaid Services (CMS). Since 2009, CPT recognizes the total duration spent by a physician on a given date, even if the time spent by the physician on that date is not continuous; the time involves both face-to-face time and unit/floor time.⁵ CMS only attributes direct face-to-face time between the physician and the patient toward prolonged care billing. Time spent reviewing charts or discussion of a patient with house medical staff, waiting for test results, waiting for changes in the patient’s condition, waiting for end of a therapy session, or waiting for use of facilities cannot be billed as prolonged services.5 This is in direct opposition to its policy for C/CC services, and makes prolonged care services inefficient.

Medicare also identifies “threshold” time (see Table 2). The total physician visit time must exceed the time requirements associated with the “primary” codes by a 30-minute threshold (e.g. 99221+99356=30 minutes+30 minutes=60 minutes threshold time). The physician must document the total face-to-face time spent in separate notes throughout the day or, more realistically, in one cumulative note.

When two providers from the same group and same specialty perform services on the same date (e.g. physician A saw the patient during morning rounds, and physician B spoke with the patient/family in the afternoon), only one physician can report the cumulative service.⁶ As always, query payors for coverage, because some non-Medicare insurers do not recognize these codes.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

References

1. Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual: Chapter 12, Section 30.6.1B. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 8, 2012.
2. Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual: Chapter 12, Section 30.6.1C. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 8, 2012.
3. Centers for Medicare & Medicaid Services (CMS). Medicare National Coverage Determinations Manual: Chapter 1, Section 70.1. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/manuals/downloads/ncd103c1_Part1.pdf. Accessed Jan. 8, 2012.
4. Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual: Chapter 12, Section 30.6.15.1C. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 8, 2012.
5. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011:7-21.
6. Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual: Chapter 12, Section 30.6.5. Centers for Medicare & Medicaid Services website. Available at: www.cms.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 8, 2012.

A project to formalize “local leadership models”—partnering leadership teams comprising a hospitalist and a nurse manager on each participating unit—at the University of Michigan Health System helped to redefine the role of unit medical director and led to allocating sufficient time (15% to 20% of an FTE) for hospitalists to fill that role. The process also led to a joint role description for the physician and nurse leaders.

“In our organization, we had the medical director concept in place previously, but things were missing, with no direct accountability, no dedicated effort, and lack of clarity on reporting,” explains hospitalist Christopher Kim, MD, MBA, lead author of an article about the project published in the American Journal of Medical Quality.¹ “We learned from other organizations, and one of the first things we learned was to make sure we hired the right person as medical director. We need an energetic, enthusiastic physician who can reach out to nurses and bridge gaps in communication and coordination of care.”

The clinical partnership model was piloted on five units—four adult and one pediatric—and has since been adopted by eight others. The physician/nurse leaders work on such issues as improving care transitions, reducing pressure ulcers and catheter-related urinary tract infections, developing multi-disciplinary rounding on the units, and sharing quality data with staff.

“Take UTIs or pressure ulcers; we’re all familiar with recommended practice, but how it gets played out on the units varies. If team leaders understand this, they can champion the processes and

create an educational push for them,” Dr. Kim says. “Those organizations that have done this well cite higher staff satisfaction as a result.”

Study results show that the initial five units were “among the highest-performing units in our facility on satisfaction,” he adds. “It’s an exciting opportunity to bring change processes necessary to build a local clinical care environment that will improve the overall experience of the patient.”

Reference

1. Kim CS, Calarco M, Jacobs T, et al. Leadership at the front line: A clinical partnership model on general care inpatient units. Am J Med Qual. 2011 (epub ahead of print).

A project to formalize “local leadership models”—partnering leadership teams comprising a hospitalist and a nurse manager on each participating unit—at the University of Michigan Health System helped to redefine the role of unit medical director and led to allocating sufficient time (15% to 20% of an FTE) for hospitalists to fill that role. The process also led to a joint role description for the physician and nurse leaders.

“In our organization, we had the medical director concept in place previously, but things were missing, with no direct accountability, no dedicated effort, and lack of clarity on reporting,” explains hospitalist Christopher Kim, MD, MBA, lead author of an article about the project published in the American Journal of Medical Quality.¹ “We learned from other organizations, and one of the first things we learned was to make sure we hired the right person as medical director. We need an energetic, enthusiastic physician who can reach out to nurses and bridge gaps in communication and coordination of care.”

The clinical partnership model was piloted on five units—four adult and one pediatric—and has since been adopted by eight others. The physician/nurse leaders work on such issues as improving care transitions, reducing pressure ulcers and catheter-related urinary tract infections, developing multi-disciplinary rounding on the units, and sharing quality data with staff.

“Take UTIs or pressure ulcers; we’re all familiar with recommended practice, but how it gets played out on the units varies. If team leaders understand this, they can champion the processes and

create an educational push for them,” Dr. Kim says. “Those organizations that have done this well cite higher staff satisfaction as a result.”

Study results show that the initial five units were “among the highest-performing units in our facility on satisfaction,” he adds. “It’s an exciting opportunity to bring change processes necessary to build a local clinical care environment that will improve the overall experience of the patient.”

Reference

1. Kim CS, Calarco M, Jacobs T, et al. Leadership at the front line: A clinical partnership model on general care inpatient units. Am J Med Qual. 2011 (epub ahead of print).

A project to formalize “local leadership models”—partnering leadership teams comprising a hospitalist and a nurse manager on each participating unit—at the University of Michigan Health System helped to redefine the role of unit medical director and led to allocating sufficient time (15% to 20% of an FTE) for hospitalists to fill that role. The process also led to a joint role description for the physician and nurse leaders.

“In our organization, we had the medical director concept in place previously, but things were missing, with no direct accountability, no dedicated effort, and lack of clarity on reporting,” explains hospitalist Christopher Kim, MD, MBA, lead author of an article about the project published in the American Journal of Medical Quality.¹ “We learned from other organizations, and one of the first things we learned was to make sure we hired the right person as medical director. We need an energetic, enthusiastic physician who can reach out to nurses and bridge gaps in communication and coordination of care.”

The clinical partnership model was piloted on five units—four adult and one pediatric—and has since been adopted by eight others. The physician/nurse leaders work on such issues as improving care transitions, reducing pressure ulcers and catheter-related urinary tract infections, developing multi-disciplinary rounding on the units, and sharing quality data with staff.

“Take UTIs or pressure ulcers; we’re all familiar with recommended practice, but how it gets played out on the units varies. If team leaders understand this, they can champion the processes and

create an educational push for them,” Dr. Kim says. “Those organizations that have done this well cite higher staff satisfaction as a result.”

Study results show that the initial five units were “among the highest-performing units in our facility on satisfaction,” he adds. “It’s an exciting opportunity to bring change processes necessary to build a local clinical care environment that will improve the overall experience of the patient.”

Reference

1. Kim CS, Calarco M, Jacobs T, et al. Leadership at the front line: A clinical partnership model on general care inpatient units. Am J Med Qual. 2011 (epub ahead of print).