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Yes, it’s time for another “year ahead” type column where the writer attempts to provide clarity on future events. What does “Hospital Medicine 2016” hold for us? I hope by the time Hospital Medicine 2017 rolls around, everyone will have forgotten the wrong predictions and only remember those that reveal my exceptional clairvoyance and prescient knowledge.

NP and PA Practice in Hospital Medicine Will Continue to Grow

Well, it doesn’t take a crystal ball or tarot cards to predict this. One only has to look at the data. The 2012 State of Hospital Medicine report revealed that 51.7% of hospital medicine groups (HMGs) employed nurse practitioners (NPs) and/or physician assistants (PAs) in their practice. Two short years later, the survey showed 83% of HMGs reported having NPs and/or PAs in their groups. That is an astounding amount of growth in a short period of time, which brings me to my next prediction.

HMGs Will Have to Continue to Figure Out How to Hire and Deploy NPs and PAs in Sensible Ways

I know that statement is very controversial. Not. But the true work of utilizing NP and PA providers in hospitalist practice is not in the hiring; it’s how to use these providers in thoughtful, sensible, and cost-effective ways.

A group leader really needs to know and understand the drivers behind the need for these hires as well as understand the financial landscape in the hiring. Are you hiring an NP/PA because you want to reduce your provider workforce cost? Are you hiring to target quality outcomes in a specific patient population? Are you hiring to staff your observation unit, freeing up your physicians for higher-acuity work? Are you hiring to treat and improve physician burnout? Or is this the only carbon-based life form you can attract to the outer boroughs of your northern clime in the deepest, darkest days of January?

All these may or may not be good reasons, but understanding those variables will help you get the right person for the right reason and will help you evaluate the return on investment and the impact on practice.

Diversity Prevents Disease

Much like the potato monoculture of McDonald’s french fries increasing the risk of potato diseases, monoculture in your hospitalist group may breed burnout and bad attitudes. Diversity of experience, perspective, and skill set may inoculate your group, keeping the dreaded crispy coated from complaining about schedule, workload, or acuity or, worse yet, simply leaving.

I don’t have data to support this, but I have heard anecdotally from more than one HMG leader that the addition of NP/PA providers to physician teams has improved physician satisfaction. SHM obviously agrees with this philosophy, as they value and support the value of a “big tent” philosophy. This big tent includes all types of people who contribute to the culture of this organization, making it stronger, more nimble and innovative, and definitely more fun.

Diversity in providers can only have a positive impact on your organization’s culture.

Whatever the Reason You Hire Them, Get Ready for Change

Be prepared for evolution. You may have initially hired an NP or PA simply to do admissions or to see all of your orthopedic co-management patients. But over time, your practice is going to morph and evolve, hopefully, in positive ways. Bring your NP/PA colleagues along for the ride; pull up a chair to the table. They may be able to provide new direction, support, or service lines to your practice in ways you hadn’t considered.

NP/PA providers’ abilities and ambitions will change over time as well. Make sure that change goes both ways. You may find that their influence and impact on your organization’s productivity and growth go beyond their industry. Consider utilizing NP/PA providers in novel ways; maybe they have great onboarding skills, are fabulous at scheduling, or can look at a spreadsheet without going cross-eyed or bald.

Change is growth. And growth is good. Unless you would rather die.

HM Needs to Develop Innovative Care Models; NPs/PAs Provide a Platform for Innovation

Inpatient medicine is changing in a rapid and unpredictable way. Some of the necessity of that work is driven by financial incentives and quality indicators, but necessity is the biggest driver of all. People, patients, and providers are getting old (thank God it’s not just me). There simply are not enough physicians to care for our rapidly aging population, or if there are, they are all employed in sunny Southern California. How we respond to this threat or opportunity is one of our most important charges. We own the inpatient kingdom. We need to lead with benevolence and thoughtfulness. We need to really look ahead and identify new ways to manage the complexity of a system whose complexity continues to mutate like some avian virus. I can’t see a future without a crucial role played by my NP/PA brethren. Can we begin this conversation with the long view in mind and really begin to own this in a true and responsible way?

Thanks for your attention, and remember, in 2017 you will have forgotten all the ways, if any, that I was wrong. TH

Ms. Cardin is a nurse practitioner in the Section of Hospital Medicine at the University of Chicago and is chair of SHM’s NP/PA Committee. She is a newly elected SHM board member.

Yes, it’s time for another “year ahead” type column where the writer attempts to provide clarity on future events. What does “Hospital Medicine 2016” hold for us? I hope by the time Hospital Medicine 2017 rolls around, everyone will have forgotten the wrong predictions and only remember those that reveal my exceptional clairvoyance and prescient knowledge.

NP and PA Practice in Hospital Medicine Will Continue to Grow

Well, it doesn’t take a crystal ball or tarot cards to predict this. One only has to look at the data. The 2012 State of Hospital Medicine report revealed that 51.7% of hospital medicine groups (HMGs) employed nurse practitioners (NPs) and/or physician assistants (PAs) in their practice. Two short years later, the survey showed 83% of HMGs reported having NPs and/or PAs in their groups. That is an astounding amount of growth in a short period of time, which brings me to my next prediction.

HMGs Will Have to Continue to Figure Out How to Hire and Deploy NPs and PAs in Sensible Ways

I know that statement is very controversial. Not. But the true work of utilizing NP and PA providers in hospitalist practice is not in the hiring; it’s how to use these providers in thoughtful, sensible, and cost-effective ways.

A group leader really needs to know and understand the drivers behind the need for these hires as well as understand the financial landscape in the hiring. Are you hiring an NP/PA because you want to reduce your provider workforce cost? Are you hiring to target quality outcomes in a specific patient population? Are you hiring to staff your observation unit, freeing up your physicians for higher-acuity work? Are you hiring to treat and improve physician burnout? Or is this the only carbon-based life form you can attract to the outer boroughs of your northern clime in the deepest, darkest days of January?

All these may or may not be good reasons, but understanding those variables will help you get the right person for the right reason and will help you evaluate the return on investment and the impact on practice.

Diversity Prevents Disease

Much like the potato monoculture of McDonald’s french fries increasing the risk of potato diseases, monoculture in your hospitalist group may breed burnout and bad attitudes. Diversity of experience, perspective, and skill set may inoculate your group, keeping the dreaded crispy coated from complaining about schedule, workload, or acuity or, worse yet, simply leaving.

I don’t have data to support this, but I have heard anecdotally from more than one HMG leader that the addition of NP/PA providers to physician teams has improved physician satisfaction. SHM obviously agrees with this philosophy, as they value and support the value of a “big tent” philosophy. This big tent includes all types of people who contribute to the culture of this organization, making it stronger, more nimble and innovative, and definitely more fun.

Diversity in providers can only have a positive impact on your organization’s culture.

Whatever the Reason You Hire Them, Get Ready for Change

Be prepared for evolution. You may have initially hired an NP or PA simply to do admissions or to see all of your orthopedic co-management patients. But over time, your practice is going to morph and evolve, hopefully, in positive ways. Bring your NP/PA colleagues along for the ride; pull up a chair to the table. They may be able to provide new direction, support, or service lines to your practice in ways you hadn’t considered.

NP/PA providers’ abilities and ambitions will change over time as well. Make sure that change goes both ways. You may find that their influence and impact on your organization’s productivity and growth go beyond their industry. Consider utilizing NP/PA providers in novel ways; maybe they have great onboarding skills, are fabulous at scheduling, or can look at a spreadsheet without going cross-eyed or bald.

Change is growth. And growth is good. Unless you would rather die.

HM Needs to Develop Innovative Care Models; NPs/PAs Provide a Platform for Innovation

Inpatient medicine is changing in a rapid and unpredictable way. Some of the necessity of that work is driven by financial incentives and quality indicators, but necessity is the biggest driver of all. People, patients, and providers are getting old (thank God it’s not just me). There simply are not enough physicians to care for our rapidly aging population, or if there are, they are all employed in sunny Southern California. How we respond to this threat or opportunity is one of our most important charges. We own the inpatient kingdom. We need to lead with benevolence and thoughtfulness. We need to really look ahead and identify new ways to manage the complexity of a system whose complexity continues to mutate like some avian virus. I can’t see a future without a crucial role played by my NP/PA brethren. Can we begin this conversation with the long view in mind and really begin to own this in a true and responsible way?

Thanks for your attention, and remember, in 2017 you will have forgotten all the ways, if any, that I was wrong. TH

Ms. Cardin is a nurse practitioner in the Section of Hospital Medicine at the University of Chicago and is chair of SHM’s NP/PA Committee. She is a newly elected SHM board member.

Yes, it’s time for another “year ahead” type column where the writer attempts to provide clarity on future events. What does “Hospital Medicine 2016” hold for us? I hope by the time Hospital Medicine 2017 rolls around, everyone will have forgotten the wrong predictions and only remember those that reveal my exceptional clairvoyance and prescient knowledge.

NP and PA Practice in Hospital Medicine Will Continue to Grow

Well, it doesn’t take a crystal ball or tarot cards to predict this. One only has to look at the data. The 2012 State of Hospital Medicine report revealed that 51.7% of hospital medicine groups (HMGs) employed nurse practitioners (NPs) and/or physician assistants (PAs) in their practice. Two short years later, the survey showed 83% of HMGs reported having NPs and/or PAs in their groups. That is an astounding amount of growth in a short period of time, which brings me to my next prediction.

HMGs Will Have to Continue to Figure Out How to Hire and Deploy NPs and PAs in Sensible Ways

I know that statement is very controversial. Not. But the true work of utilizing NP and PA providers in hospitalist practice is not in the hiring; it’s how to use these providers in thoughtful, sensible, and cost-effective ways.

A group leader really needs to know and understand the drivers behind the need for these hires as well as understand the financial landscape in the hiring. Are you hiring an NP/PA because you want to reduce your provider workforce cost? Are you hiring to target quality outcomes in a specific patient population? Are you hiring to staff your observation unit, freeing up your physicians for higher-acuity work? Are you hiring to treat and improve physician burnout? Or is this the only carbon-based life form you can attract to the outer boroughs of your northern clime in the deepest, darkest days of January?

All these may or may not be good reasons, but understanding those variables will help you get the right person for the right reason and will help you evaluate the return on investment and the impact on practice.

Diversity Prevents Disease

Much like the potato monoculture of McDonald’s french fries increasing the risk of potato diseases, monoculture in your hospitalist group may breed burnout and bad attitudes. Diversity of experience, perspective, and skill set may inoculate your group, keeping the dreaded crispy coated from complaining about schedule, workload, or acuity or, worse yet, simply leaving.

I don’t have data to support this, but I have heard anecdotally from more than one HMG leader that the addition of NP/PA providers to physician teams has improved physician satisfaction. SHM obviously agrees with this philosophy, as they value and support the value of a “big tent” philosophy. This big tent includes all types of people who contribute to the culture of this organization, making it stronger, more nimble and innovative, and definitely more fun.

Diversity in providers can only have a positive impact on your organization’s culture.

Whatever the Reason You Hire Them, Get Ready for Change

Be prepared for evolution. You may have initially hired an NP or PA simply to do admissions or to see all of your orthopedic co-management patients. But over time, your practice is going to morph and evolve, hopefully, in positive ways. Bring your NP/PA colleagues along for the ride; pull up a chair to the table. They may be able to provide new direction, support, or service lines to your practice in ways you hadn’t considered.

NP/PA providers’ abilities and ambitions will change over time as well. Make sure that change goes both ways. You may find that their influence and impact on your organization’s productivity and growth go beyond their industry. Consider utilizing NP/PA providers in novel ways; maybe they have great onboarding skills, are fabulous at scheduling, or can look at a spreadsheet without going cross-eyed or bald.

Change is growth. And growth is good. Unless you would rather die.

HM Needs to Develop Innovative Care Models; NPs/PAs Provide a Platform for Innovation

Inpatient medicine is changing in a rapid and unpredictable way. Some of the necessity of that work is driven by financial incentives and quality indicators, but necessity is the biggest driver of all. People, patients, and providers are getting old (thank God it’s not just me). There simply are not enough physicians to care for our rapidly aging population, or if there are, they are all employed in sunny Southern California. How we respond to this threat or opportunity is one of our most important charges. We own the inpatient kingdom. We need to lead with benevolence and thoughtfulness. We need to really look ahead and identify new ways to manage the complexity of a system whose complexity continues to mutate like some avian virus. I can’t see a future without a crucial role played by my NP/PA brethren. Can we begin this conversation with the long view in mind and really begin to own this in a true and responsible way?

Thanks for your attention, and remember, in 2017 you will have forgotten all the ways, if any, that I was wrong. TH

Ms. Cardin is a nurse practitioner in the Section of Hospital Medicine at the University of Chicago and is chair of SHM’s NP/PA Committee. She is a newly elected SHM board member.

ATLANTA (Reuters) - Did you get enough sleep last night? If not, you are not alone. More than one out of three American adults do not get enough sleep, according to a study released Thursday from the U.S. Centers for Disease Control and Prevention.

"That's a big problem," says Dr. Nancy Collop, director of the Emory Sleep Center at Emory University School of Medicine in Atlanta, who is familiar with the study. "You don't function as well, your ability to pay attention is reduced, and it can have serious, long term side effects. It can change your metabolism for the worse."

At least seven hours of sleep is considered healthy for an adults aged 18 to 60, according to the American Academy of Sleep Medicine and the Sleep Research Society. The CDC analyzed data from a 2014 survey of 444,306 adults and found roughly 65% of respondents reported getting that amount of

sleep.

"Lifestyle changes such as going to bed at the same time each night; rising at the same time each morning; and turning off or removing televisions, computers, mobile devices from the bedroom, can help people get the healthy sleep they need," said Dr. Wayne Giles, director of the CDC's Division of Population Health, in a statement.

Getting less than seven hours a night is associated with an increased risk of obesity, diabetes, high blood pressure, heart disease, stroke and frequent mental distress, the study shows. Published in the CDC's Morbidity and Mortality Weekly Report, the study is the first of its kind to look at all 50 U.S. states and the District of Columbia.

The study found that among those most likely to get great sleep were married or have a job, with 67% and 65%, respectively saying they get enough. Only 56% of divorced adults said they get enough sleep, and just over half of jobless adults sleep seven hours a night regularly. Among the best sleepers were college graduates, with 72% reporting seven hours or more.

The study found geographical differences as well as ethnic disparities. Hawaiian residents get less sleep than those living in South Dakota, the study found. Non-Hispanic whites sleep better than non-Hispanic black residents, with 67% and 54%, respectively.

ATLANTA (Reuters) - Did you get enough sleep last night? If not, you are not alone. More than one out of three American adults do not get enough sleep, according to a study released Thursday from the U.S. Centers for Disease Control and Prevention.

"That's a big problem," says Dr. Nancy Collop, director of the Emory Sleep Center at Emory University School of Medicine in Atlanta, who is familiar with the study. "You don't function as well, your ability to pay attention is reduced, and it can have serious, long term side effects. It can change your metabolism for the worse."

At least seven hours of sleep is considered healthy for an adults aged 18 to 60, according to the American Academy of Sleep Medicine and the Sleep Research Society. The CDC analyzed data from a 2014 survey of 444,306 adults and found roughly 65% of respondents reported getting that amount of

sleep.

"Lifestyle changes such as going to bed at the same time each night; rising at the same time each morning; and turning off or removing televisions, computers, mobile devices from the bedroom, can help people get the healthy sleep they need," said Dr. Wayne Giles, director of the CDC's Division of Population Health, in a statement.

Getting less than seven hours a night is associated with an increased risk of obesity, diabetes, high blood pressure, heart disease, stroke and frequent mental distress, the study shows. Published in the CDC's Morbidity and Mortality Weekly Report, the study is the first of its kind to look at all 50 U.S. states and the District of Columbia.

The study found that among those most likely to get great sleep were married or have a job, with 67% and 65%, respectively saying they get enough. Only 56% of divorced adults said they get enough sleep, and just over half of jobless adults sleep seven hours a night regularly. Among the best sleepers were college graduates, with 72% reporting seven hours or more.

The study found geographical differences as well as ethnic disparities. Hawaiian residents get less sleep than those living in South Dakota, the study found. Non-Hispanic whites sleep better than non-Hispanic black residents, with 67% and 54%, respectively.

ATLANTA (Reuters) - Did you get enough sleep last night? If not, you are not alone. More than one out of three American adults do not get enough sleep, according to a study released Thursday from the U.S. Centers for Disease Control and Prevention.

"That's a big problem," says Dr. Nancy Collop, director of the Emory Sleep Center at Emory University School of Medicine in Atlanta, who is familiar with the study. "You don't function as well, your ability to pay attention is reduced, and it can have serious, long term side effects. It can change your metabolism for the worse."

At least seven hours of sleep is considered healthy for an adults aged 18 to 60, according to the American Academy of Sleep Medicine and the Sleep Research Society. The CDC analyzed data from a 2014 survey of 444,306 adults and found roughly 65% of respondents reported getting that amount of

sleep.

"Lifestyle changes such as going to bed at the same time each night; rising at the same time each morning; and turning off or removing televisions, computers, mobile devices from the bedroom, can help people get the healthy sleep they need," said Dr. Wayne Giles, director of the CDC's Division of Population Health, in a statement.

Getting less than seven hours a night is associated with an increased risk of obesity, diabetes, high blood pressure, heart disease, stroke and frequent mental distress, the study shows. Published in the CDC's Morbidity and Mortality Weekly Report, the study is the first of its kind to look at all 50 U.S. states and the District of Columbia.

The study found that among those most likely to get great sleep were married or have a job, with 67% and 65%, respectively saying they get enough. Only 56% of divorced adults said they get enough sleep, and just over half of jobless adults sleep seven hours a night regularly. Among the best sleepers were college graduates, with 72% reporting seven hours or more.

The study found geographical differences as well as ethnic disparities. Hawaiian residents get less sleep than those living in South Dakota, the study found. Non-Hispanic whites sleep better than non-Hispanic black residents, with 67% and 54%, respectively.

D. Holt, Arkansas

S. Bhansali, MD, California

E. Bhansin, BS, DO, California

A. Bogart, MD, California

D. Donald, MD, California

S. Evans, FNP, California

R. Godbout, California

E. Gustafson, MD, California

M. Hasan, MD, California

M. Kantor, MD, California

M. McClellan, California

A. Milin, MD, California

E. Nguyen, California

J. Young, BSN, RN, California

M. Hicks, MD, Colorado

J. Tyler, DO, Colorado

P. Sharma, MHA, Connecticut

J. Meyer, DO, Florida

M. Prabhu, ACMPE, Florida

K. Slazinski, MD, MA, Florida

P. Zipper, Florida

S. Gayle, MD, Georgia

N. Palmer, DO, Georgia

R. Schaefer, MD, Hawaii

E. Diehl, MD, Iowa

C. Kuehn, MD, Iowa

A. Buchwach, MD, Illinois

F. Evangelista, MD, Illinois

S. Kurup, Illinois

J. Shanahan, Illinois

U. Tekin, MD, Illinois

C. Dennis, Massachusetts

D. Gewanter, Massachusetts

S. Master, MD, Massachusetts

C. Mathew, MD, Massachusetts

M. Sakr, MD, Massachusetts

M. Mason, PA-C, Maryland

M. Kowalczyk, ACNP, Minnesota

M. Doose, MD, Minnesota

F. Abualrub, Missouri

R. Adkison, DO, Missouri

S. Katukoori, MD, Missouri

A. Persaud, PA-C, Missouri

L. Gerstle, NP, Montana

S. Brown, MD, North Carolina

S. Okorie, New Jersey

P. Mathew, MD, New Mexico

A. Turney, DO, Nevada

J. Chester, MD, New York

C. Flynn, DO, New York

M. Hoefer, PMGR, New York

M. Islam, MD, New York

C. Karno, MD, New York

S. Mir, New York

P. Nadkarni, MD, New York

A. Rana, New York

G. Rubinfeld, New York

A. Black, MBA, Ohio

R. Cartabuke, MHA, Ohio

P. He, DO, Ohio

R. Rivero, DO, Ohio

K. Welch, Ohio

S. Parker, APRN-BC, Oklahoma

T. Basra, MD, MBBS, Oregon

B. Baxter, Oregon

S. Mehta, MD, Oregon

V. Karper, ACNP, Pennsylvania

D. Messner, MSN, NP, Pennsylvania

M. Scoulos-Hanson, Pennsylvania

K. Willoughby, MD, Pennsylvania

R. Yazdanfar, MD, Pennsylvania

J. Hennessey, CCFP, Canada

J. Brown, MD, South Carolina

K. Medlin, RN, South Carolina

K. Kays, Tennessee

M. Begum, MD, Texas

S. Blinchevsky, MD, Texas

C. Ciborowski, Texas

K. Gupta, MD, Texas

H. Lam, MD, Texas

A. Owens, Texas

K. Salciccioli, BSE, Texas

D. Lundberg, Wisconsin

H. Peto, Wisconsin

B. Quinn, MD, Wisconsin

N. Ros, PhD, Spain

S. Takeuchi, MD, Japan

D. Holt, Arkansas

S. Bhansali, MD, California

E. Bhansin, BS, DO, California

A. Bogart, MD, California

D. Donald, MD, California

S. Evans, FNP, California

R. Godbout, California

E. Gustafson, MD, California

M. Hasan, MD, California

M. Kantor, MD, California

M. McClellan, California

A. Milin, MD, California

E. Nguyen, California

J. Young, BSN, RN, California

M. Hicks, MD, Colorado

J. Tyler, DO, Colorado

P. Sharma, MHA, Connecticut

J. Meyer, DO, Florida

M. Prabhu, ACMPE, Florida

K. Slazinski, MD, MA, Florida

P. Zipper, Florida

S. Gayle, MD, Georgia

N. Palmer, DO, Georgia

R. Schaefer, MD, Hawaii

E. Diehl, MD, Iowa

C. Kuehn, MD, Iowa

A. Buchwach, MD, Illinois

F. Evangelista, MD, Illinois

S. Kurup, Illinois

J. Shanahan, Illinois

U. Tekin, MD, Illinois

C. Dennis, Massachusetts

D. Gewanter, Massachusetts

S. Master, MD, Massachusetts

C. Mathew, MD, Massachusetts

M. Sakr, MD, Massachusetts

M. Mason, PA-C, Maryland

M. Kowalczyk, ACNP, Minnesota

M. Doose, MD, Minnesota

F. Abualrub, Missouri

R. Adkison, DO, Missouri

S. Katukoori, MD, Missouri

A. Persaud, PA-C, Missouri

L. Gerstle, NP, Montana

S. Brown, MD, North Carolina

S. Okorie, New Jersey

P. Mathew, MD, New Mexico

A. Turney, DO, Nevada

J. Chester, MD, New York

C. Flynn, DO, New York

M. Hoefer, PMGR, New York

M. Islam, MD, New York

C. Karno, MD, New York

S. Mir, New York

P. Nadkarni, MD, New York

A. Rana, New York

G. Rubinfeld, New York

A. Black, MBA, Ohio

R. Cartabuke, MHA, Ohio

P. He, DO, Ohio

R. Rivero, DO, Ohio

K. Welch, Ohio

S. Parker, APRN-BC, Oklahoma

T. Basra, MD, MBBS, Oregon

B. Baxter, Oregon

S. Mehta, MD, Oregon

V. Karper, ACNP, Pennsylvania

D. Messner, MSN, NP, Pennsylvania

M. Scoulos-Hanson, Pennsylvania

K. Willoughby, MD, Pennsylvania

R. Yazdanfar, MD, Pennsylvania

J. Hennessey, CCFP, Canada

J. Brown, MD, South Carolina

K. Medlin, RN, South Carolina

K. Kays, Tennessee

M. Begum, MD, Texas

S. Blinchevsky, MD, Texas

C. Ciborowski, Texas

K. Gupta, MD, Texas

H. Lam, MD, Texas

A. Owens, Texas

K. Salciccioli, BSE, Texas

D. Lundberg, Wisconsin

H. Peto, Wisconsin

B. Quinn, MD, Wisconsin

N. Ros, PhD, Spain

S. Takeuchi, MD, Japan

D. Holt, Arkansas

S. Bhansali, MD, California

E. Bhansin, BS, DO, California

A. Bogart, MD, California

D. Donald, MD, California

S. Evans, FNP, California

R. Godbout, California

E. Gustafson, MD, California

M. Hasan, MD, California

M. Kantor, MD, California

M. McClellan, California

A. Milin, MD, California

E. Nguyen, California

J. Young, BSN, RN, California

M. Hicks, MD, Colorado

J. Tyler, DO, Colorado

P. Sharma, MHA, Connecticut

J. Meyer, DO, Florida

M. Prabhu, ACMPE, Florida

K. Slazinski, MD, MA, Florida

P. Zipper, Florida

S. Gayle, MD, Georgia

N. Palmer, DO, Georgia

R. Schaefer, MD, Hawaii

E. Diehl, MD, Iowa

C. Kuehn, MD, Iowa

A. Buchwach, MD, Illinois

F. Evangelista, MD, Illinois

S. Kurup, Illinois

J. Shanahan, Illinois

U. Tekin, MD, Illinois

C. Dennis, Massachusetts

D. Gewanter, Massachusetts

S. Master, MD, Massachusetts

C. Mathew, MD, Massachusetts

M. Sakr, MD, Massachusetts

M. Mason, PA-C, Maryland

M. Kowalczyk, ACNP, Minnesota

M. Doose, MD, Minnesota

F. Abualrub, Missouri

R. Adkison, DO, Missouri

S. Katukoori, MD, Missouri

A. Persaud, PA-C, Missouri

L. Gerstle, NP, Montana

S. Brown, MD, North Carolina

S. Okorie, New Jersey

P. Mathew, MD, New Mexico

A. Turney, DO, Nevada

J. Chester, MD, New York

C. Flynn, DO, New York

M. Hoefer, PMGR, New York

M. Islam, MD, New York

C. Karno, MD, New York

S. Mir, New York

P. Nadkarni, MD, New York

A. Rana, New York

G. Rubinfeld, New York

A. Black, MBA, Ohio

R. Cartabuke, MHA, Ohio

P. He, DO, Ohio

R. Rivero, DO, Ohio

K. Welch, Ohio

S. Parker, APRN-BC, Oklahoma

T. Basra, MD, MBBS, Oregon

B. Baxter, Oregon

S. Mehta, MD, Oregon

V. Karper, ACNP, Pennsylvania

D. Messner, MSN, NP, Pennsylvania

M. Scoulos-Hanson, Pennsylvania

K. Willoughby, MD, Pennsylvania

R. Yazdanfar, MD, Pennsylvania

J. Hennessey, CCFP, Canada

J. Brown, MD, South Carolina

K. Medlin, RN, South Carolina

K. Kays, Tennessee

M. Begum, MD, Texas

S. Blinchevsky, MD, Texas

C. Ciborowski, Texas

K. Gupta, MD, Texas

H. Lam, MD, Texas

A. Owens, Texas

K. Salciccioli, BSE, Texas

D. Lundberg, Wisconsin

H. Peto, Wisconsin

B. Quinn, MD, Wisconsin

N. Ros, PhD, Spain

S. Takeuchi, MD, Japan

The Centers for Medicare & Medicaid Services (CMS) recently announced the approval of a dedicated specialty billing code for hospitalists that will soon be ready for official use. This is a monumental step for hospital medicine, which continues to be the fastest growing medical specialty in the U.S., with more than 48,000 practitioners identifying as hospitalists.

The Hospitalist recently discussed the implications of this decision with Ron Greeno, MD, MHM, chief strategy officer for IPC Healthcare and chair of SHM’s Public Policy Committee (PPC), and Josh Boswell, director of government relations at SHM, to answer questions raised by SHM members.

Question: What are the benefits to hospitalists using the code?

Dr. Greeno: As we transition from fee-for-service to quality-based payment models, using this code will become critical to ensure hospitalists are reimbursed and evaluated fairly. Under the current code structure, hospitalists are missing opportunities to be rewarded and may be penalized unnecessarily because they are required to identify with internal medicine, family medicine, or another specialty that most closely resembles their daily practice. What current measures do not account for is that hospitalists’ patients are inherently more complex than those seen by practitioners in these other—most often outpatient—specialties. We as hospitalists face unique challenges and work with patients from all demographics, often with severe illnesses, making it nearly impossible to rely on benchmarks used for these other specialties.

There are a few prime examples of this that illustrate the need for the new code. Under the current system, some quality-based patient satisfaction measures under MACRA, on which hospitalists are being evaluated, pertain to the outpatient setting, including waiting room quality and office staff–irrelevant measurements for hospitalists. Hospitalists are also often incorrectly penalized under meaningful use due to complications brought on by observation status and its classification as an outpatient stay. This can cause both quality and cost measures to be extremely flawed and can misrepresent the performance and cost of hospitalists and hospital medicine groups. In the current billing structure, there is no way to accurately identify hospitalists and enable a definite fix to these problems.

To get what we want (fair measurement using relevant metrics), we must be able to identify as a separate group, and fortunately, now we can. There will be benefits we don’t even know about yet. We have to wait and see how healthcare policy continues to evolve and change moving forward. What we do know is that having this code will help us shape MACRA and future healthcare policy so that it works better for hospitalists as the specialty continues to grow in scope and impact.

Q: When will the new code go into effect?

Boswell: While there is not a set date at this time, CMS has reported that it can take up to a year, mostly due to technical changes that need to be made within their own systems. The code has already been officially approved; we just need to wait a bit longer to actually use it.

Q: What happens to hospitalists if they do not use the code?

Dr. Greeno: Some hospitalists might be nervous about the change after having billed a certain way for so long. While there is no absolute requirement for hospitalists to use the new code, the bottom line is that if hospitalists do not adopt the new code, they risk not receiving fair evaluations. Using this code should provide hospitalists with greater insight into their own performance—the data will be much more accurate and meaningful. This will allow hospitalists to hone in on areas needing improvement and provide them with more confidence that they are being compared using accurate benchmarks.

I want to stress that hospitalists, or in some cases their hospital medicine groups, will need to physically change their specialty affiliation when the code becomes effective. Otherwise, they risk not reaping the benefits associated with the new code and will continue to be evaluated using less-than-optimal benchmarks. The ball is in their court to make the change when the code is available, and SHM will serve as a resource to help ensure they know what to do and when.

Q: Where can someone go to find the code? Will it be available on the CMS website?

Boswell: When the code does become available for use, it will be communicated through various channels at SHM and also through the Medicare Learning Network, the site that houses education, information, and resources for healthcare professionals. It will also likely be distributed through additional Medicare circulars and newsletters.

As more details from CMS become available, we will have more specific information to share with members, including information on our website, webinars with billing and coding experts, email communication, and more. Continue to watch your email and social media channels for the latest updates and information.

 Q: What role did SHM play in bringing this code to fruition?

Boswell: We can say with confidence that this effort was driven entirely by SHM. To start, a formal application needs to be filed in order for a code to even be considered. After determining that the benefits associated with this code far outweighed the costs and then receiving the support of our board of directors, SHM’s staff and PPC members collaborated to draft a brief and made the argument for the addition of a hospitalist billing code based on the individual elements CMS requires for consideration.

Due to the fact hospital medicine doesn’t have a board certification, while solid, our argument was far from a slam dunk. After submitting the application, SHM continuously followed up with and pressured CMS through various channels and utilized our grassroots network of hospitalists on the Hill to put this code on legislators’ radars—the result was pressure getting applied from interested members of Congress as well. If it weren’t for the persistent advocacy efforts of SHM and its members over the past several years, this code would not have even been considered, let alone approved.

This is a significant development—to our knowledge, this is the first medical specialty to be granted a code without also having a board certification. We’re thrilled that what we have been advocating for on behalf of our members is now a reality!

For the latest information on the new hospitalist billing code and other important healthcare policy updates, continue to check for SHM emails and follow SHM’s social media channels, including @SHMLive and @SHMAdvocacy on Twitter.

Sign up for the network to get the latest news in healthcare policy and discover opportunities to advocate for yourself and fellow hospitalists. TH

Brett Radler is SHM’s communications coordinator.

The Centers for Medicare & Medicaid Services (CMS) recently announced the approval of a dedicated specialty billing code for hospitalists that will soon be ready for official use. This is a monumental step for hospital medicine, which continues to be the fastest growing medical specialty in the U.S., with more than 48,000 practitioners identifying as hospitalists.

The Hospitalist recently discussed the implications of this decision with Ron Greeno, MD, MHM, chief strategy officer for IPC Healthcare and chair of SHM’s Public Policy Committee (PPC), and Josh Boswell, director of government relations at SHM, to answer questions raised by SHM members.

Question: What are the benefits to hospitalists using the code?

Dr. Greeno: As we transition from fee-for-service to quality-based payment models, using this code will become critical to ensure hospitalists are reimbursed and evaluated fairly. Under the current code structure, hospitalists are missing opportunities to be rewarded and may be penalized unnecessarily because they are required to identify with internal medicine, family medicine, or another specialty that most closely resembles their daily practice. What current measures do not account for is that hospitalists’ patients are inherently more complex than those seen by practitioners in these other—most often outpatient—specialties. We as hospitalists face unique challenges and work with patients from all demographics, often with severe illnesses, making it nearly impossible to rely on benchmarks used for these other specialties.

There are a few prime examples of this that illustrate the need for the new code. Under the current system, some quality-based patient satisfaction measures under MACRA, on which hospitalists are being evaluated, pertain to the outpatient setting, including waiting room quality and office staff–irrelevant measurements for hospitalists. Hospitalists are also often incorrectly penalized under meaningful use due to complications brought on by observation status and its classification as an outpatient stay. This can cause both quality and cost measures to be extremely flawed and can misrepresent the performance and cost of hospitalists and hospital medicine groups. In the current billing structure, there is no way to accurately identify hospitalists and enable a definite fix to these problems.

To get what we want (fair measurement using relevant metrics), we must be able to identify as a separate group, and fortunately, now we can. There will be benefits we don’t even know about yet. We have to wait and see how healthcare policy continues to evolve and change moving forward. What we do know is that having this code will help us shape MACRA and future healthcare policy so that it works better for hospitalists as the specialty continues to grow in scope and impact.

Q: When will the new code go into effect?

Boswell: While there is not a set date at this time, CMS has reported that it can take up to a year, mostly due to technical changes that need to be made within their own systems. The code has already been officially approved; we just need to wait a bit longer to actually use it.

Q: What happens to hospitalists if they do not use the code?

Dr. Greeno: Some hospitalists might be nervous about the change after having billed a certain way for so long. While there is no absolute requirement for hospitalists to use the new code, the bottom line is that if hospitalists do not adopt the new code, they risk not receiving fair evaluations. Using this code should provide hospitalists with greater insight into their own performance—the data will be much more accurate and meaningful. This will allow hospitalists to hone in on areas needing improvement and provide them with more confidence that they are being compared using accurate benchmarks.

I want to stress that hospitalists, or in some cases their hospital medicine groups, will need to physically change their specialty affiliation when the code becomes effective. Otherwise, they risk not reaping the benefits associated with the new code and will continue to be evaluated using less-than-optimal benchmarks. The ball is in their court to make the change when the code is available, and SHM will serve as a resource to help ensure they know what to do and when.

Q: Where can someone go to find the code? Will it be available on the CMS website?

Boswell: When the code does become available for use, it will be communicated through various channels at SHM and also through the Medicare Learning Network, the site that houses education, information, and resources for healthcare professionals. It will also likely be distributed through additional Medicare circulars and newsletters.

As more details from CMS become available, we will have more specific information to share with members, including information on our website, webinars with billing and coding experts, email communication, and more. Continue to watch your email and social media channels for the latest updates and information.

 Q: What role did SHM play in bringing this code to fruition?

Boswell: We can say with confidence that this effort was driven entirely by SHM. To start, a formal application needs to be filed in order for a code to even be considered. After determining that the benefits associated with this code far outweighed the costs and then receiving the support of our board of directors, SHM’s staff and PPC members collaborated to draft a brief and made the argument for the addition of a hospitalist billing code based on the individual elements CMS requires for consideration.

Due to the fact hospital medicine doesn’t have a board certification, while solid, our argument was far from a slam dunk. After submitting the application, SHM continuously followed up with and pressured CMS through various channels and utilized our grassroots network of hospitalists on the Hill to put this code on legislators’ radars—the result was pressure getting applied from interested members of Congress as well. If it weren’t for the persistent advocacy efforts of SHM and its members over the past several years, this code would not have even been considered, let alone approved.

This is a significant development—to our knowledge, this is the first medical specialty to be granted a code without also having a board certification. We’re thrilled that what we have been advocating for on behalf of our members is now a reality!

For the latest information on the new hospitalist billing code and other important healthcare policy updates, continue to check for SHM emails and follow SHM’s social media channels, including @SHMLive and @SHMAdvocacy on Twitter.

Sign up for the network to get the latest news in healthcare policy and discover opportunities to advocate for yourself and fellow hospitalists. TH

Brett Radler is SHM’s communications coordinator.

The Centers for Medicare & Medicaid Services (CMS) recently announced the approval of a dedicated specialty billing code for hospitalists that will soon be ready for official use. This is a monumental step for hospital medicine, which continues to be the fastest growing medical specialty in the U.S., with more than 48,000 practitioners identifying as hospitalists.

The Hospitalist recently discussed the implications of this decision with Ron Greeno, MD, MHM, chief strategy officer for IPC Healthcare and chair of SHM’s Public Policy Committee (PPC), and Josh Boswell, director of government relations at SHM, to answer questions raised by SHM members.

Question: What are the benefits to hospitalists using the code?

Dr. Greeno: As we transition from fee-for-service to quality-based payment models, using this code will become critical to ensure hospitalists are reimbursed and evaluated fairly. Under the current code structure, hospitalists are missing opportunities to be rewarded and may be penalized unnecessarily because they are required to identify with internal medicine, family medicine, or another specialty that most closely resembles their daily practice. What current measures do not account for is that hospitalists’ patients are inherently more complex than those seen by practitioners in these other—most often outpatient—specialties. We as hospitalists face unique challenges and work with patients from all demographics, often with severe illnesses, making it nearly impossible to rely on benchmarks used for these other specialties.

There are a few prime examples of this that illustrate the need for the new code. Under the current system, some quality-based patient satisfaction measures under MACRA, on which hospitalists are being evaluated, pertain to the outpatient setting, including waiting room quality and office staff–irrelevant measurements for hospitalists. Hospitalists are also often incorrectly penalized under meaningful use due to complications brought on by observation status and its classification as an outpatient stay. This can cause both quality and cost measures to be extremely flawed and can misrepresent the performance and cost of hospitalists and hospital medicine groups. In the current billing structure, there is no way to accurately identify hospitalists and enable a definite fix to these problems.

To get what we want (fair measurement using relevant metrics), we must be able to identify as a separate group, and fortunately, now we can. There will be benefits we don’t even know about yet. We have to wait and see how healthcare policy continues to evolve and change moving forward. What we do know is that having this code will help us shape MACRA and future healthcare policy so that it works better for hospitalists as the specialty continues to grow in scope and impact.

Q: When will the new code go into effect?

Boswell: While there is not a set date at this time, CMS has reported that it can take up to a year, mostly due to technical changes that need to be made within their own systems. The code has already been officially approved; we just need to wait a bit longer to actually use it.

Q: What happens to hospitalists if they do not use the code?

Dr. Greeno: Some hospitalists might be nervous about the change after having billed a certain way for so long. While there is no absolute requirement for hospitalists to use the new code, the bottom line is that if hospitalists do not adopt the new code, they risk not receiving fair evaluations. Using this code should provide hospitalists with greater insight into their own performance—the data will be much more accurate and meaningful. This will allow hospitalists to hone in on areas needing improvement and provide them with more confidence that they are being compared using accurate benchmarks.

I want to stress that hospitalists, or in some cases their hospital medicine groups, will need to physically change their specialty affiliation when the code becomes effective. Otherwise, they risk not reaping the benefits associated with the new code and will continue to be evaluated using less-than-optimal benchmarks. The ball is in their court to make the change when the code is available, and SHM will serve as a resource to help ensure they know what to do and when.

Q: Where can someone go to find the code? Will it be available on the CMS website?

Boswell: When the code does become available for use, it will be communicated through various channels at SHM and also through the Medicare Learning Network, the site that houses education, information, and resources for healthcare professionals. It will also likely be distributed through additional Medicare circulars and newsletters.

As more details from CMS become available, we will have more specific information to share with members, including information on our website, webinars with billing and coding experts, email communication, and more. Continue to watch your email and social media channels for the latest updates and information.

 Q: What role did SHM play in bringing this code to fruition?

Boswell: We can say with confidence that this effort was driven entirely by SHM. To start, a formal application needs to be filed in order for a code to even be considered. After determining that the benefits associated with this code far outweighed the costs and then receiving the support of our board of directors, SHM’s staff and PPC members collaborated to draft a brief and made the argument for the addition of a hospitalist billing code based on the individual elements CMS requires for consideration.

Due to the fact hospital medicine doesn’t have a board certification, while solid, our argument was far from a slam dunk. After submitting the application, SHM continuously followed up with and pressured CMS through various channels and utilized our grassroots network of hospitalists on the Hill to put this code on legislators’ radars—the result was pressure getting applied from interested members of Congress as well. If it weren’t for the persistent advocacy efforts of SHM and its members over the past several years, this code would not have even been considered, let alone approved.

This is a significant development—to our knowledge, this is the first medical specialty to be granted a code without also having a board certification. We’re thrilled that what we have been advocating for on behalf of our members is now a reality!

For the latest information on the new hospitalist billing code and other important healthcare policy updates, continue to check for SHM emails and follow SHM’s social media channels, including @SHMLive and @SHMAdvocacy on Twitter.

Sign up for the network to get the latest news in healthcare policy and discover opportunities to advocate for yourself and fellow hospitalists. TH

Brett Radler is SHM’s communications coordinator.

Sound clinical reasoning is the foundation of patient safety, yet discussions of a physician’s raw thinking ability have become a “third rail” in hospitals, according to “Incorporating Metacognition into Morbidity and Mortality Rounds: The Next Frontier in Quality Improvement,” published in the Journal of Hospital Medicine. Authors David Katz, MD, MSc, and Allan S. Detsky, MD, PhD, suggest introducing concepts from cognitive psychology could help address this issue.

The underlying problem is that the search for causes of medical error focuses on systems-based issues—medication administration and dosing, communication, physician handover, etc. There’s a reluctance to talk about human decision making. In fact, in the authors’ own hospitals, improving diagnostic accuracy is almost never discussed; they suspect the same is true at other institutions.

But cognitive errors occur predictably and often, especially at times of high cognitive load (i.e., when many complex decisions are being made in a short period of time), according to research from cognitive psychology. The authors therefore suggest that introducing metacognition (or “thinking about thinking”) discussions during morbidity and mortality rounds (MMRs) might help expand the discussions so that human error can be recognized and addressed.

They suggest that cognitive heuristics be introduced to MMRs by experienced and respected clinicians who can tell stories of their own errors and the shortcuts in thinking that may have caused them.

“Thereafter, the traditional MMR format can be used: presenting a case, describing how an experienced clinician might manage the case, and then asking the audience members for comment,” they write. “Incorporating discussions of cognitive missteps, in medical and nonmedical contexts, would help normalize the understanding that even the most experienced and smartest people fall prey to them. The tone must be positive.”

Reference

1. Katz D, Detsky AS. Incorporating metacognition into morbidity and mortality rounds: the next frontier in quality improvement. J Hosp Med. 2016;11(2):120-122. doi:10.1002/jhm.2505.

Sound clinical reasoning is the foundation of patient safety, yet discussions of a physician’s raw thinking ability have become a “third rail” in hospitals, according to “Incorporating Metacognition into Morbidity and Mortality Rounds: The Next Frontier in Quality Improvement,” published in the Journal of Hospital Medicine. Authors David Katz, MD, MSc, and Allan S. Detsky, MD, PhD, suggest introducing concepts from cognitive psychology could help address this issue.

The underlying problem is that the search for causes of medical error focuses on systems-based issues—medication administration and dosing, communication, physician handover, etc. There’s a reluctance to talk about human decision making. In fact, in the authors’ own hospitals, improving diagnostic accuracy is almost never discussed; they suspect the same is true at other institutions.

But cognitive errors occur predictably and often, especially at times of high cognitive load (i.e., when many complex decisions are being made in a short period of time), according to research from cognitive psychology. The authors therefore suggest that introducing metacognition (or “thinking about thinking”) discussions during morbidity and mortality rounds (MMRs) might help expand the discussions so that human error can be recognized and addressed.

They suggest that cognitive heuristics be introduced to MMRs by experienced and respected clinicians who can tell stories of their own errors and the shortcuts in thinking that may have caused them.

“Thereafter, the traditional MMR format can be used: presenting a case, describing how an experienced clinician might manage the case, and then asking the audience members for comment,” they write. “Incorporating discussions of cognitive missteps, in medical and nonmedical contexts, would help normalize the understanding that even the most experienced and smartest people fall prey to them. The tone must be positive.”

Reference

1. Katz D, Detsky AS. Incorporating metacognition into morbidity and mortality rounds: the next frontier in quality improvement. J Hosp Med. 2016;11(2):120-122. doi:10.1002/jhm.2505.

Sound clinical reasoning is the foundation of patient safety, yet discussions of a physician’s raw thinking ability have become a “third rail” in hospitals, according to “Incorporating Metacognition into Morbidity and Mortality Rounds: The Next Frontier in Quality Improvement,” published in the Journal of Hospital Medicine. Authors David Katz, MD, MSc, and Allan S. Detsky, MD, PhD, suggest introducing concepts from cognitive psychology could help address this issue.

The underlying problem is that the search for causes of medical error focuses on systems-based issues—medication administration and dosing, communication, physician handover, etc. There’s a reluctance to talk about human decision making. In fact, in the authors’ own hospitals, improving diagnostic accuracy is almost never discussed; they suspect the same is true at other institutions.

But cognitive errors occur predictably and often, especially at times of high cognitive load (i.e., when many complex decisions are being made in a short period of time), according to research from cognitive psychology. The authors therefore suggest that introducing metacognition (or “thinking about thinking”) discussions during morbidity and mortality rounds (MMRs) might help expand the discussions so that human error can be recognized and addressed.

They suggest that cognitive heuristics be introduced to MMRs by experienced and respected clinicians who can tell stories of their own errors and the shortcuts in thinking that may have caused them.

“Thereafter, the traditional MMR format can be used: presenting a case, describing how an experienced clinician might manage the case, and then asking the audience members for comment,” they write. “Incorporating discussions of cognitive missteps, in medical and nonmedical contexts, would help normalize the understanding that even the most experienced and smartest people fall prey to them. The tone must be positive.”

Reference

1. Katz D, Detsky AS. Incorporating metacognition into morbidity and mortality rounds: the next frontier in quality improvement. J Hosp Med. 2016;11(2):120-122. doi:10.1002/jhm.2505.

NEW YORK (Reuters Health) - Cardiac resynchronization therapy (CRT) in patients with heart failure (HF) without left bundle branch block (LBBB) may not help and might even harm, according to an international group of investigators.

As Dr. Yitschak Biton told Reuters Health by email, "Our findings suggest that patients without LBBB electrocardiogram (ECG) morphology are not likely to benefit from CRT implantation and a subgroup of patients with short QRS duration might even be at higher risk for mortality."

In a January 28 online paper in Circulation: Heart Failure, Dr. Biton, of the University of Rochester Medical Center, New York, and colleagues note that the efficacy of CRT is well established in patients with both mild and moderate to severe HF symptoms. However, data on non-LBBB patients "are more limited and conflicting."

To investigate, the team examined data on 537 such patients with mild HF taking part in a larger study. At seven years, the cumulative probability of HF hospitalization or death was 45% in those randomized to an implantable cardioverter-defibrillator (ICD) and 56% in those given CRT with a defibrillator (CRT-D).

Multivariable-adjusted subgroup analysis by QRS duration showed that patients from the lower quartile (134 ms or less) had a 2.4-fold greater risk of HF hospitalization or death with CRT-D versus those with ICD-only therapy.

However, the effect of CRT-D in patients from the upper quartiles group (QRS greater than 134 ms) was neutral (hazard ratio 0.97).

In a further analysis based on PR interval, patients with prolonged QRS (more than 134 ms) and prolonged PR (at least 230 ms) were protected with CRT-D (HR 0.31). The association was neutral with prolonged QRS and shorter PR.

"Overall," the researchers conclude, "patients with mild HF but without left bundle branch block morphology did not derive clinical benefit with CRT-D during long-term follow-up. Relatively shorter QRS was associated with a significantly increased risk with CRT-D relative to implantable cardioverter-defibrillator only."

"This information should be taken into account when CRT therapy is considered in this subgroup of patients," Dr. Biton told Reuters Health.

Boston Scientific Corporation funded the clinical trial this research is based on. Five coauthors reported disclosures.

NEW YORK (Reuters Health) - Cardiac resynchronization therapy (CRT) in patients with heart failure (HF) without left bundle branch block (LBBB) may not help and might even harm, according to an international group of investigators.

As Dr. Yitschak Biton told Reuters Health by email, "Our findings suggest that patients without LBBB electrocardiogram (ECG) morphology are not likely to benefit from CRT implantation and a subgroup of patients with short QRS duration might even be at higher risk for mortality."

In a January 28 online paper in Circulation: Heart Failure, Dr. Biton, of the University of Rochester Medical Center, New York, and colleagues note that the efficacy of CRT is well established in patients with both mild and moderate to severe HF symptoms. However, data on non-LBBB patients "are more limited and conflicting."

To investigate, the team examined data on 537 such patients with mild HF taking part in a larger study. At seven years, the cumulative probability of HF hospitalization or death was 45% in those randomized to an implantable cardioverter-defibrillator (ICD) and 56% in those given CRT with a defibrillator (CRT-D).

Multivariable-adjusted subgroup analysis by QRS duration showed that patients from the lower quartile (134 ms or less) had a 2.4-fold greater risk of HF hospitalization or death with CRT-D versus those with ICD-only therapy.

However, the effect of CRT-D in patients from the upper quartiles group (QRS greater than 134 ms) was neutral (hazard ratio 0.97).

In a further analysis based on PR interval, patients with prolonged QRS (more than 134 ms) and prolonged PR (at least 230 ms) were protected with CRT-D (HR 0.31). The association was neutral with prolonged QRS and shorter PR.

"Overall," the researchers conclude, "patients with mild HF but without left bundle branch block morphology did not derive clinical benefit with CRT-D during long-term follow-up. Relatively shorter QRS was associated with a significantly increased risk with CRT-D relative to implantable cardioverter-defibrillator only."

"This information should be taken into account when CRT therapy is considered in this subgroup of patients," Dr. Biton told Reuters Health.

Boston Scientific Corporation funded the clinical trial this research is based on. Five coauthors reported disclosures.

NEW YORK (Reuters Health) - Cardiac resynchronization therapy (CRT) in patients with heart failure (HF) without left bundle branch block (LBBB) may not help and might even harm, according to an international group of investigators.

As Dr. Yitschak Biton told Reuters Health by email, "Our findings suggest that patients without LBBB electrocardiogram (ECG) morphology are not likely to benefit from CRT implantation and a subgroup of patients with short QRS duration might even be at higher risk for mortality."

In a January 28 online paper in Circulation: Heart Failure, Dr. Biton, of the University of Rochester Medical Center, New York, and colleagues note that the efficacy of CRT is well established in patients with both mild and moderate to severe HF symptoms. However, data on non-LBBB patients "are more limited and conflicting."

To investigate, the team examined data on 537 such patients with mild HF taking part in a larger study. At seven years, the cumulative probability of HF hospitalization or death was 45% in those randomized to an implantable cardioverter-defibrillator (ICD) and 56% in those given CRT with a defibrillator (CRT-D).

Multivariable-adjusted subgroup analysis by QRS duration showed that patients from the lower quartile (134 ms or less) had a 2.4-fold greater risk of HF hospitalization or death with CRT-D versus those with ICD-only therapy.

However, the effect of CRT-D in patients from the upper quartiles group (QRS greater than 134 ms) was neutral (hazard ratio 0.97).

In a further analysis based on PR interval, patients with prolonged QRS (more than 134 ms) and prolonged PR (at least 230 ms) were protected with CRT-D (HR 0.31). The association was neutral with prolonged QRS and shorter PR.

"Overall," the researchers conclude, "patients with mild HF but without left bundle branch block morphology did not derive clinical benefit with CRT-D during long-term follow-up. Relatively shorter QRS was associated with a significantly increased risk with CRT-D relative to implantable cardioverter-defibrillator only."

"This information should be taken into account when CRT therapy is considered in this subgroup of patients," Dr. Biton told Reuters Health.

Boston Scientific Corporation funded the clinical trial this research is based on. Five coauthors reported disclosures.

Most healthcare systems don’t know or understand their cost of care at the unit that matters, i.e., the actual cost of care for an individual patient. Knowing this, University of Utah Health Sciences Center (UHSC) sought to develop methodologies using clinical data that would enable it to determine cost of care. Ultimately, a team led by systems, data, and analytics personnel, and including hospitalists, created an analytics framework known as value driven outcomes (VDO) using an agile methodology. Evaluation consisted of measurement against project objectives, including implementation timeliness, system performance, completeness, accuracy, extensibility, adoption, satisfaction, and the ability to support value improvement.1

“The initial results of employing the cost-savings tool have been exciting. For example, a 30% reduction in the cost of an orthopedic joint replacement—an inpatient hospital procedure—was realized,” says Robert C. Pendleton, MD, chief medical quality officer and professor of medicine at the University of Utah in Salt Lake City.

In another instance, hospitalists at UHSC led an initiative to reduce the use of unnecessary laboratory tests. That resulted in $400,000 in cost savings in the first year.

Another UHSC hospitalist used data to reduce unnecessary telemetry utilization by 60% on the hospitalist service.

“The accumulative impact of these initiatives, among others, will be a savings of millions of dollars annually by making process changes,” says Dr. Pendleton, a hospitalist who served on the executive steering committee that designed the web-based tool. “Our early experience shows that there is a lot of waste in the healthcare system.”

Along with the costing tool, quality and outcome measures were integrated so that the actual value of care (best outcomes at the lowest cost) could be assessed and incrementally improved.

Widespread Use?

Dr. Pendleton believes the tool could become popular among hospitalists, explaining that the field is known as the “leading system thinkers in healthcare.”

“By their nature, if you give them meaningful data and they can compare themselves to their peers, they are highly engaged to determine where waste in their hospitals exists and to lead improvement efforts,” he says.

UHSC is currently in the process of rolling out the VDO tool systemwide to its 1,200 faculty members. The rollout will take six to 12 months. In the next year, it’s also working to define and integrate outcome measures for the top 50 medical conditions it treats, which will allow it to robustly assess the value of care delivery.

“Success will equally be to increase quality without an increase in cost,” he says.

What’s more, Dr. Pendleton says efforts are in the works to make the self-intuitive system available to institutions nationwide. For example, the center is working to address technical complexities resulting from the use of multiple electronic health record vendors.

“The goal is to make it usable in every environment so we can support other organizations in the most effective ways,” he says.

Although the tool is very easy to use, stakeholders are providing feedback that allows for continuous improvements in how data are presented.

“Anyone with basic computer skills and the ability to interpret bar charts and basic graphs can use it,” Dr. Pendleton says. The center also offers a 15-minute, confidential, training module and a one-hour, one-on-one training session with an analyst. TH

Karen Appold is a freelance author in Pennsylvania.

Reference

1. Kawamoto K, Martin CJ, Williams K, et al. Value driven outcomes (VDO): a pragmatic, modular, and extensible software framework for understanding and improving health care costs and outcomes. J Am Med Inform Assoc. 2015;22(1):223-235.

Most healthcare systems don’t know or understand their cost of care at the unit that matters, i.e., the actual cost of care for an individual patient. Knowing this, University of Utah Health Sciences Center (UHSC) sought to develop methodologies using clinical data that would enable it to determine cost of care. Ultimately, a team led by systems, data, and analytics personnel, and including hospitalists, created an analytics framework known as value driven outcomes (VDO) using an agile methodology. Evaluation consisted of measurement against project objectives, including implementation timeliness, system performance, completeness, accuracy, extensibility, adoption, satisfaction, and the ability to support value improvement.1

“The initial results of employing the cost-savings tool have been exciting. For example, a 30% reduction in the cost of an orthopedic joint replacement—an inpatient hospital procedure—was realized,” says Robert C. Pendleton, MD, chief medical quality officer and professor of medicine at the University of Utah in Salt Lake City.

In another instance, hospitalists at UHSC led an initiative to reduce the use of unnecessary laboratory tests. That resulted in $400,000 in cost savings in the first year.

Another UHSC hospitalist used data to reduce unnecessary telemetry utilization by 60% on the hospitalist service.

“The accumulative impact of these initiatives, among others, will be a savings of millions of dollars annually by making process changes,” says Dr. Pendleton, a hospitalist who served on the executive steering committee that designed the web-based tool. “Our early experience shows that there is a lot of waste in the healthcare system.”

Along with the costing tool, quality and outcome measures were integrated so that the actual value of care (best outcomes at the lowest cost) could be assessed and incrementally improved.

Widespread Use?

Dr. Pendleton believes the tool could become popular among hospitalists, explaining that the field is known as the “leading system thinkers in healthcare.”

“By their nature, if you give them meaningful data and they can compare themselves to their peers, they are highly engaged to determine where waste in their hospitals exists and to lead improvement efforts,” he says.

UHSC is currently in the process of rolling out the VDO tool systemwide to its 1,200 faculty members. The rollout will take six to 12 months. In the next year, it’s also working to define and integrate outcome measures for the top 50 medical conditions it treats, which will allow it to robustly assess the value of care delivery.

“Success will equally be to increase quality without an increase in cost,” he says.

What’s more, Dr. Pendleton says efforts are in the works to make the self-intuitive system available to institutions nationwide. For example, the center is working to address technical complexities resulting from the use of multiple electronic health record vendors.

“The goal is to make it usable in every environment so we can support other organizations in the most effective ways,” he says.

Although the tool is very easy to use, stakeholders are providing feedback that allows for continuous improvements in how data are presented.

“Anyone with basic computer skills and the ability to interpret bar charts and basic graphs can use it,” Dr. Pendleton says. The center also offers a 15-minute, confidential, training module and a one-hour, one-on-one training session with an analyst. TH

Karen Appold is a freelance author in Pennsylvania.

Reference

1. Kawamoto K, Martin CJ, Williams K, et al. Value driven outcomes (VDO): a pragmatic, modular, and extensible software framework for understanding and improving health care costs and outcomes. J Am Med Inform Assoc. 2015;22(1):223-235.

Most healthcare systems don’t know or understand their cost of care at the unit that matters, i.e., the actual cost of care for an individual patient. Knowing this, University of Utah Health Sciences Center (UHSC) sought to develop methodologies using clinical data that would enable it to determine cost of care. Ultimately, a team led by systems, data, and analytics personnel, and including hospitalists, created an analytics framework known as value driven outcomes (VDO) using an agile methodology. Evaluation consisted of measurement against project objectives, including implementation timeliness, system performance, completeness, accuracy, extensibility, adoption, satisfaction, and the ability to support value improvement.1

“The initial results of employing the cost-savings tool have been exciting. For example, a 30% reduction in the cost of an orthopedic joint replacement—an inpatient hospital procedure—was realized,” says Robert C. Pendleton, MD, chief medical quality officer and professor of medicine at the University of Utah in Salt Lake City.

In another instance, hospitalists at UHSC led an initiative to reduce the use of unnecessary laboratory tests. That resulted in $400,000 in cost savings in the first year.

Another UHSC hospitalist used data to reduce unnecessary telemetry utilization by 60% on the hospitalist service.

“The accumulative impact of these initiatives, among others, will be a savings of millions of dollars annually by making process changes,” says Dr. Pendleton, a hospitalist who served on the executive steering committee that designed the web-based tool. “Our early experience shows that there is a lot of waste in the healthcare system.”

Along with the costing tool, quality and outcome measures were integrated so that the actual value of care (best outcomes at the lowest cost) could be assessed and incrementally improved.

Widespread Use?

Dr. Pendleton believes the tool could become popular among hospitalists, explaining that the field is known as the “leading system thinkers in healthcare.”

“By their nature, if you give them meaningful data and they can compare themselves to their peers, they are highly engaged to determine where waste in their hospitals exists and to lead improvement efforts,” he says.

UHSC is currently in the process of rolling out the VDO tool systemwide to its 1,200 faculty members. The rollout will take six to 12 months. In the next year, it’s also working to define and integrate outcome measures for the top 50 medical conditions it treats, which will allow it to robustly assess the value of care delivery.

“Success will equally be to increase quality without an increase in cost,” he says.

What’s more, Dr. Pendleton says efforts are in the works to make the self-intuitive system available to institutions nationwide. For example, the center is working to address technical complexities resulting from the use of multiple electronic health record vendors.

“The goal is to make it usable in every environment so we can support other organizations in the most effective ways,” he says.

Although the tool is very easy to use, stakeholders are providing feedback that allows for continuous improvements in how data are presented.

“Anyone with basic computer skills and the ability to interpret bar charts and basic graphs can use it,” Dr. Pendleton says. The center also offers a 15-minute, confidential, training module and a one-hour, one-on-one training session with an analyst. TH

Karen Appold is a freelance author in Pennsylvania.

Reference

1. Kawamoto K, Martin CJ, Williams K, et al. Value driven outcomes (VDO): a pragmatic, modular, and extensible software framework for understanding and improving health care costs and outcomes. J Am Med Inform Assoc. 2015;22(1):223-235.

(Reuters Health) - Having sleep apnea may increase the risk of chronic kidney disease, according to a report from Taiwan.

Researchers analyzed data from 2000 through 2010 on 8,600 adults diagnosed with sleep apnea and four times as many adults of similar age, sex and monthly income without sleep apnea, using Taiwan's National Health Insurance Research Database.

They found 157 new cases of chronic kidney disease among people with sleep apnea and 298 cases in the comparison group, according to Yung-Tai Chen of Taipei City Hospital Heping Fuyou Branch in Taiwan and coauthors.

After taking other health factors into account, sleep apnea increased the risk of kidney disease by 58%. By comparison, hypertension (a known risk factor for kidney disease) increased the risk by 17%. Diabetes was a stronger predictor than both other factors, more than doubling the risk of kidney disease, the research team reported online February 1 in Respirology.

Intermittent low oxygen levels during the night and fragmented sleep patterns may activate higher blood pressure, which would damage the kidneys and could make individuals more susceptible to chronic kidney disease, said Tetyana Kendzerska of the University of Toronto Institute for Clinical Evaluative Sciences, who was not part of the study in Taiwan.

But, "the findings from this study are limited by lack of information on sleep apnea and chronic kidney disease severity given that these conditions were defined through the health administrative data," Kendzerska said.

Factors like obesity and smoking status are also important for kidney risk but were not included in the assessment, she told Reuters Health by email.

"So, instead of concluding that sleep apnea has the same impact as high blood pressure on the kidney, I would rather conclude that this study suggests that the association between sleep apnea and chronic kidney disease may exist," and should be validated with more powerful studies, she said.

Moderate to severe obstructive sleep apnea can be treated with continuous positive airway pressure (CPAP) at night which may decrease high blood pressure and mitigate kidney risk, Kendzerska said.

"These findings raise the issue of whether the relationship between sleep apnea and chronic kidney disease is unidirectional or bidirectional," she said. "If the importance of sleep apnea and preventive effect of treatment will be confirmed in further studies, sleep apnea should be added to the list of modifiable risk factors considered in (chronic kidney disease) risk assessment."

The authors of the study did not respond to a request for comment.

(Reuters Health) - Having sleep apnea may increase the risk of chronic kidney disease, according to a report from Taiwan.

Researchers analyzed data from 2000 through 2010 on 8,600 adults diagnosed with sleep apnea and four times as many adults of similar age, sex and monthly income without sleep apnea, using Taiwan's National Health Insurance Research Database.

They found 157 new cases of chronic kidney disease among people with sleep apnea and 298 cases in the comparison group, according to Yung-Tai Chen of Taipei City Hospital Heping Fuyou Branch in Taiwan and coauthors.

After taking other health factors into account, sleep apnea increased the risk of kidney disease by 58%. By comparison, hypertension (a known risk factor for kidney disease) increased the risk by 17%. Diabetes was a stronger predictor than both other factors, more than doubling the risk of kidney disease, the research team reported online February 1 in Respirology.

Intermittent low oxygen levels during the night and fragmented sleep patterns may activate higher blood pressure, which would damage the kidneys and could make individuals more susceptible to chronic kidney disease, said Tetyana Kendzerska of the University of Toronto Institute for Clinical Evaluative Sciences, who was not part of the study in Taiwan.

But, "the findings from this study are limited by lack of information on sleep apnea and chronic kidney disease severity given that these conditions were defined through the health administrative data," Kendzerska said.

Factors like obesity and smoking status are also important for kidney risk but were not included in the assessment, she told Reuters Health by email.

"So, instead of concluding that sleep apnea has the same impact as high blood pressure on the kidney, I would rather conclude that this study suggests that the association between sleep apnea and chronic kidney disease may exist," and should be validated with more powerful studies, she said.

Moderate to severe obstructive sleep apnea can be treated with continuous positive airway pressure (CPAP) at night which may decrease high blood pressure and mitigate kidney risk, Kendzerska said.

"These findings raise the issue of whether the relationship between sleep apnea and chronic kidney disease is unidirectional or bidirectional," she said. "If the importance of sleep apnea and preventive effect of treatment will be confirmed in further studies, sleep apnea should be added to the list of modifiable risk factors considered in (chronic kidney disease) risk assessment."

The authors of the study did not respond to a request for comment.

(Reuters Health) - Having sleep apnea may increase the risk of chronic kidney disease, according to a report from Taiwan.

Researchers analyzed data from 2000 through 2010 on 8,600 adults diagnosed with sleep apnea and four times as many adults of similar age, sex and monthly income without sleep apnea, using Taiwan's National Health Insurance Research Database.

They found 157 new cases of chronic kidney disease among people with sleep apnea and 298 cases in the comparison group, according to Yung-Tai Chen of Taipei City Hospital Heping Fuyou Branch in Taiwan and coauthors.

After taking other health factors into account, sleep apnea increased the risk of kidney disease by 58%. By comparison, hypertension (a known risk factor for kidney disease) increased the risk by 17%. Diabetes was a stronger predictor than both other factors, more than doubling the risk of kidney disease, the research team reported online February 1 in Respirology.

Intermittent low oxygen levels during the night and fragmented sleep patterns may activate higher blood pressure, which would damage the kidneys and could make individuals more susceptible to chronic kidney disease, said Tetyana Kendzerska of the University of Toronto Institute for Clinical Evaluative Sciences, who was not part of the study in Taiwan.

But, "the findings from this study are limited by lack of information on sleep apnea and chronic kidney disease severity given that these conditions were defined through the health administrative data," Kendzerska said.

Factors like obesity and smoking status are also important for kidney risk but were not included in the assessment, she told Reuters Health by email.

"So, instead of concluding that sleep apnea has the same impact as high blood pressure on the kidney, I would rather conclude that this study suggests that the association between sleep apnea and chronic kidney disease may exist," and should be validated with more powerful studies, she said.

Moderate to severe obstructive sleep apnea can be treated with continuous positive airway pressure (CPAP) at night which may decrease high blood pressure and mitigate kidney risk, Kendzerska said.

"These findings raise the issue of whether the relationship between sleep apnea and chronic kidney disease is unidirectional or bidirectional," she said. "If the importance of sleep apnea and preventive effect of treatment will be confirmed in further studies, sleep apnea should be added to the list of modifiable risk factors considered in (chronic kidney disease) risk assessment."

The authors of the study did not respond to a request for comment.

Early in 2015, SHM published the updated edition of the “Key Principles and Characteristics of an Effective Hospital Medicine Group,” which is a free download via the SHM website. Every hospitalist group should use this comprehensive list of attributes as one important frame of reference to guide ongoing improvement efforts and long-range planning.

In this column and the next two, I’ll split the difference between the very brief list of top success factors for hospitalist groups I wrote about in my March 2011 column and the very comprehensive “Key Characteristics” document. I think these attributes are among the most important to support a high-performing group, yet they are sometimes overlooked or implemented poorly. They are of roughly equal importance and are listed in no particular order.

Deliberately Cultivating a Culture (or Mindset) of Practice Ownership

It’s easy for hospitalists to think of themselves as employees who just work shifts but have no need or opportunity to attend to the bigger picture of the practice or the hospital in which they operate. After all, being a good doctor for your patients is an awfully big job itself, and lots of recruitment ads tell you doctoring is all that will be expected of you. Someone else will handle everything necessary to ensure your practice is successful.

This line of thinking will limit the success of your group.

Your group will perform much better and you’re likely to find your career much more rewarding if you and your hospitalist colleagues think of yourselves as owning your practice and take an active role in managing it. You’ll still need others to manage day-to-day business affairs, but at least a portion of the hospitalists in the group should be actively involved in planning and making decisions about the group’s operations and future evolution.

I encounter hospitalist groups that have become convinced they don’t even have the opportunity to shape or influence their practice. “No one ever listens,” they say. “The hospital executives just do what they want regardless of what we say.” But in nearly every case, that is an exaggeration. Most administrative leaders desperately want hospitalist engagement and thoughtful participation in planning and decision making.

I wrote additional thoughts about the importance of a culture, or mindset, of practice ownership in August 2008. The print version of that column included a short list of questions you could ask yourself to assess whether your own group has such a culture, but it is missing from the web version and can be found at nelsonflores.com/html/quiz.html.

A Formal System of Group ‘Governance’

So many hospitalist groups rely almost entirely on consensus to make decisions. This might work well enough for a very small group (e.g., four or five doctors), but for large groups, it means just one or two dissenters can block a decision and nothing much gets done.

Disagreements about practice operations and future direction are common, so every group should commit to writing some method of how votes will be taken in the absence of consensus. For example, the group might be divided about whether to adopt unit-based assignments or change the hours of an evening (“swing”) shift, and a formal vote might be the only way to make a decision. It’s best if you have decided in advance issues such as what constitutes a quorum, who is eligible to vote, and whether the winning vote requires a simple or super-majority. And a formalized system of voting helps support a culture ownership.

I wrote about this originally in December 2007 and provided sample bylaws your group could modify as needed. Of course, you should keep in mind that if you are indeed employed by a larger entity such as a hospital or staffing company, you don’t have the ability to make all decisions by a vote of the group. Pay raises, staff additions, and similar decisions require support of the employer, and while a vote in support of them might influence what actually happens, it still requires the support of the employer. But there are lots of things, like the work schedule, system of allocating patients across providers, etc., that are usually best made by the group itself, and sometimes they might come down to a vote of the group.

Never Stop Recruiting and Ensure Hospitalists Themselves Are Actively Engaged in Recruiting

I wrote about recruiting originally in July 2008 when there was a shortage of hospitalists everywhere. Since then, the supply of doctors seeking work as a hospitalist has caught up with demand in many major metropolitan areas like Minneapolis and Washington, D.C.

But outside of large markets—that is, in most of the country—demand for hospitalists still far exceeds supply, and groups face ongoing staffing deficits that come with the need for existing doctors to work extra shifts and use locum tenens or other forms of temporary staffing. The potential excess supply of hospitalists in major markets may eventually trickle out and ease the shortages elsewhere, but that hasn’t happened in a big way yet. So for these places, it is crucial to devote a lot of energy and resources to recruiting.

A vital component of successful recruiting is participation in the effort by the hospitalists themselves. I think the best mindset for the hospitalists is to think of themselves as leading recruitment efforts assisted by recruiters rather than the other way around. For example, the lead hospitalist or some other designated doctor should try to respond by phone (if that’s impractical, then respond by email) to every reasonable inquiry from a new candidate within 24 hours and serve as the candidate’s principle point of communication throughout the recruitment process. The recruiter can handle details of things like arranging travel for an interview, but a hospitalist in the group should be the main source of information regarding things like the work schedule, patient volume, compensation, etc. And a hospitalist should serve as the main host during a candidate’s on-site interview.

More to Come …

Next month, I’ll address things like a written policy and procedure manual, clear reporting relationships for the hospitalist group, and roles for advanced practice clinicians (NPs and PAs). TH

Early in 2015, SHM published the updated edition of the “Key Principles and Characteristics of an Effective Hospital Medicine Group,” which is a free download via the SHM website. Every hospitalist group should use this comprehensive list of attributes as one important frame of reference to guide ongoing improvement efforts and long-range planning.

In this column and the next two, I’ll split the difference between the very brief list of top success factors for hospitalist groups I wrote about in my March 2011 column and the very comprehensive “Key Characteristics” document. I think these attributes are among the most important to support a high-performing group, yet they are sometimes overlooked or implemented poorly. They are of roughly equal importance and are listed in no particular order.

Deliberately Cultivating a Culture (or Mindset) of Practice Ownership

It’s easy for hospitalists to think of themselves as employees who just work shifts but have no need or opportunity to attend to the bigger picture of the practice or the hospital in which they operate. After all, being a good doctor for your patients is an awfully big job itself, and lots of recruitment ads tell you doctoring is all that will be expected of you. Someone else will handle everything necessary to ensure your practice is successful.

This line of thinking will limit the success of your group.

Your group will perform much better and you’re likely to find your career much more rewarding if you and your hospitalist colleagues think of yourselves as owning your practice and take an active role in managing it. You’ll still need others to manage day-to-day business affairs, but at least a portion of the hospitalists in the group should be actively involved in planning and making decisions about the group’s operations and future evolution.

I encounter hospitalist groups that have become convinced they don’t even have the opportunity to shape or influence their practice. “No one ever listens,” they say. “The hospital executives just do what they want regardless of what we say.” But in nearly every case, that is an exaggeration. Most administrative leaders desperately want hospitalist engagement and thoughtful participation in planning and decision making.

I wrote additional thoughts about the importance of a culture, or mindset, of practice ownership in August 2008. The print version of that column included a short list of questions you could ask yourself to assess whether your own group has such a culture, but it is missing from the web version and can be found at nelsonflores.com/html/quiz.html.

A Formal System of Group ‘Governance’

So many hospitalist groups rely almost entirely on consensus to make decisions. This might work well enough for a very small group (e.g., four or five doctors), but for large groups, it means just one or two dissenters can block a decision and nothing much gets done.

Disagreements about practice operations and future direction are common, so every group should commit to writing some method of how votes will be taken in the absence of consensus. For example, the group might be divided about whether to adopt unit-based assignments or change the hours of an evening (“swing”) shift, and a formal vote might be the only way to make a decision. It’s best if you have decided in advance issues such as what constitutes a quorum, who is eligible to vote, and whether the winning vote requires a simple or super-majority. And a formalized system of voting helps support a culture ownership.

I wrote about this originally in December 2007 and provided sample bylaws your group could modify as needed. Of course, you should keep in mind that if you are indeed employed by a larger entity such as a hospital or staffing company, you don’t have the ability to make all decisions by a vote of the group. Pay raises, staff additions, and similar decisions require support of the employer, and while a vote in support of them might influence what actually happens, it still requires the support of the employer. But there are lots of things, like the work schedule, system of allocating patients across providers, etc., that are usually best made by the group itself, and sometimes they might come down to a vote of the group.

Never Stop Recruiting and Ensure Hospitalists Themselves Are Actively Engaged in Recruiting

I wrote about recruiting originally in July 2008 when there was a shortage of hospitalists everywhere. Since then, the supply of doctors seeking work as a hospitalist has caught up with demand in many major metropolitan areas like Minneapolis and Washington, D.C.

But outside of large markets—that is, in most of the country—demand for hospitalists still far exceeds supply, and groups face ongoing staffing deficits that come with the need for existing doctors to work extra shifts and use locum tenens or other forms of temporary staffing. The potential excess supply of hospitalists in major markets may eventually trickle out and ease the shortages elsewhere, but that hasn’t happened in a big way yet. So for these places, it is crucial to devote a lot of energy and resources to recruiting.

A vital component of successful recruiting is participation in the effort by the hospitalists themselves. I think the best mindset for the hospitalists is to think of themselves as leading recruitment efforts assisted by recruiters rather than the other way around. For example, the lead hospitalist or some other designated doctor should try to respond by phone (if that’s impractical, then respond by email) to every reasonable inquiry from a new candidate within 24 hours and serve as the candidate’s principle point of communication throughout the recruitment process. The recruiter can handle details of things like arranging travel for an interview, but a hospitalist in the group should be the main source of information regarding things like the work schedule, patient volume, compensation, etc. And a hospitalist should serve as the main host during a candidate’s on-site interview.

More to Come …

Next month, I’ll address things like a written policy and procedure manual, clear reporting relationships for the hospitalist group, and roles for advanced practice clinicians (NPs and PAs). TH

Early in 2015, SHM published the updated edition of the “Key Principles and Characteristics of an Effective Hospital Medicine Group,” which is a free download via the SHM website. Every hospitalist group should use this comprehensive list of attributes as one important frame of reference to guide ongoing improvement efforts and long-range planning.

In this column and the next two, I’ll split the difference between the very brief list of top success factors for hospitalist groups I wrote about in my March 2011 column and the very comprehensive “Key Characteristics” document. I think these attributes are among the most important to support a high-performing group, yet they are sometimes overlooked or implemented poorly. They are of roughly equal importance and are listed in no particular order.

Deliberately Cultivating a Culture (or Mindset) of Practice Ownership

It’s easy for hospitalists to think of themselves as employees who just work shifts but have no need or opportunity to attend to the bigger picture of the practice or the hospital in which they operate. After all, being a good doctor for your patients is an awfully big job itself, and lots of recruitment ads tell you doctoring is all that will be expected of you. Someone else will handle everything necessary to ensure your practice is successful.

This line of thinking will limit the success of your group.

Your group will perform much better and you’re likely to find your career much more rewarding if you and your hospitalist colleagues think of yourselves as owning your practice and take an active role in managing it. You’ll still need others to manage day-to-day business affairs, but at least a portion of the hospitalists in the group should be actively involved in planning and making decisions about the group’s operations and future evolution.

I encounter hospitalist groups that have become convinced they don’t even have the opportunity to shape or influence their practice. “No one ever listens,” they say. “The hospital executives just do what they want regardless of what we say.” But in nearly every case, that is an exaggeration. Most administrative leaders desperately want hospitalist engagement and thoughtful participation in planning and decision making.

I wrote additional thoughts about the importance of a culture, or mindset, of practice ownership in August 2008. The print version of that column included a short list of questions you could ask yourself to assess whether your own group has such a culture, but it is missing from the web version and can be found at nelsonflores.com/html/quiz.html.

A Formal System of Group ‘Governance’

So many hospitalist groups rely almost entirely on consensus to make decisions. This might work well enough for a very small group (e.g., four or five doctors), but for large groups, it means just one or two dissenters can block a decision and nothing much gets done.

Disagreements about practice operations and future direction are common, so every group should commit to writing some method of how votes will be taken in the absence of consensus. For example, the group might be divided about whether to adopt unit-based assignments or change the hours of an evening (“swing”) shift, and a formal vote might be the only way to make a decision. It’s best if you have decided in advance issues such as what constitutes a quorum, who is eligible to vote, and whether the winning vote requires a simple or super-majority. And a formalized system of voting helps support a culture ownership.

I wrote about this originally in December 2007 and provided sample bylaws your group could modify as needed. Of course, you should keep in mind that if you are indeed employed by a larger entity such as a hospital or staffing company, you don’t have the ability to make all decisions by a vote of the group. Pay raises, staff additions, and similar decisions require support of the employer, and while a vote in support of them might influence what actually happens, it still requires the support of the employer. But there are lots of things, like the work schedule, system of allocating patients across providers, etc., that are usually best made by the group itself, and sometimes they might come down to a vote of the group.

Never Stop Recruiting and Ensure Hospitalists Themselves Are Actively Engaged in Recruiting

I wrote about recruiting originally in July 2008 when there was a shortage of hospitalists everywhere. Since then, the supply of doctors seeking work as a hospitalist has caught up with demand in many major metropolitan areas like Minneapolis and Washington, D.C.

But outside of large markets—that is, in most of the country—demand for hospitalists still far exceeds supply, and groups face ongoing staffing deficits that come with the need for existing doctors to work extra shifts and use locum tenens or other forms of temporary staffing. The potential excess supply of hospitalists in major markets may eventually trickle out and ease the shortages elsewhere, but that hasn’t happened in a big way yet. So for these places, it is crucial to devote a lot of energy and resources to recruiting.

A vital component of successful recruiting is participation in the effort by the hospitalists themselves. I think the best mindset for the hospitalists is to think of themselves as leading recruitment efforts assisted by recruiters rather than the other way around. For example, the lead hospitalist or some other designated doctor should try to respond by phone (if that’s impractical, then respond by email) to every reasonable inquiry from a new candidate within 24 hours and serve as the candidate’s principle point of communication throughout the recruitment process. The recruiter can handle details of things like arranging travel for an interview, but a hospitalist in the group should be the main source of information regarding things like the work schedule, patient volume, compensation, etc. And a hospitalist should serve as the main host during a candidate’s on-site interview.

More to Come …

Next month, I’ll address things like a written policy and procedure manual, clear reporting relationships for the hospitalist group, and roles for advanced practice clinicians (NPs and PAs). TH

NEW YORK (Reuters Health) - Opioid modulation with the combination of buprenorphine and samidorphan (ALKS 5461) improves symptoms in patients whose depression has not responded adequately to antidepressant treatment, researchers report.

"If the findings are confirmed in phase 3 studies, ALKS 5461 could be used as an augmenting agent in patients not responding to standard antidepressant therapies as an alternative to the atypical antipsychotic agents currently approved for the treatment of this population," Dr. Maurizio Fava, from Massachusetts General Hospital and Harvard Medical School, Boston, told Reuters Health by email.

Buprenorphine is a mu- and kappa-opioid partial agonist, and samidorphan blocks the mu agonist effects of buprenorphine associated with its abuse and addictive potential. A growing body of evidence implicates dysregulation of the endogenous mu- and kappa-opioid system in mood disorders.

Dr. Fava and colleagues at 31 sites in the U.S. used a sequential parallel comparison design to investigate the efficacy of buprenorphine/samidorphan (2 mg/2 mg or 8 mg/8 mg) in 142 patients with major depression inadequately responsive to antidepressant therapy.

At the end of four weeks of treatment, patients in the ALKS 5461 2 mg/2 mg group showed significantly greater improvements in Hamilton Depression Rating Scale (HAM-D), Montgomery-Asberg Depression Rating Scale (MADRS), and Clinical Global Impression severity scores, compared with patients in the placebo group. The ALKS 5461 8 mg/8 mg group showed smaller, nonsignificant improvements.

"The overall effect sizes for the 2/2 dosage were 0.50 for HAM-D and 0.54 for MADRS," the researchers noted. "The result compares favorably with results from a meta-analysis of 14 studies with atypical antipsychotics as adjunctive therapy for major depression, with reported effect sizes of 0.35 to 0.48 for individual drugs."

Treatment response rates according to HAM-D and MADRS (at least 50% reduction in scores) were highest with ALKS 5461 2 mg/2 mg treatment group, according to the February 12 onlinereport in the American Journal of Psychiatry.

Two patients (1.6%) in the placebo group and 17 patients (19.3%) in the ALKS 5461 groups discontinued because of treatment-emergent adverse events, but there was no evidence of opioid withdrawal in any patient.

"When depressed patients do not respond to standard monoamine-based therapies for depression, consider the use of an augmenting agent that modulates other systems, such as the opioid one," Dr. Fava concluded.

Dr. Jeffrey F. Scherrer, from Saint Louis University School of Medicine, St. Louis, Missouri, recently examined the association between opioid use and increased depression rates. He told Reuters Health by email, "Our analysis of opioid use and depression did not include buprenorphine among the opioid exposure variable. Therefore, it is difficult to extrapolate our results to a trial of buprenorphine/samidorphan and major depression."

"As the authors noted, the clinical trial was of short duration and the risks of depression that we have observed appears to be greatest among those patients remaining on opioids for more than 90 days," he explained. "Additional work is currently being done to determine if some opioid medications have a greater depressogenic effect than others, which further limits direct comparison of our findings to the current study."

"I will say that it is unlikely for oxycodone, codeine, and hydrocodone (which together account for more than 90% of prescribed opioids) would help depressed patients and be more likely to worsen their depression with chronic treatment," Dr. Scherrer concluded.

Alkermes sponsored the trial, employed seven coauthors, and had various relationships with the other four coauthors.

NEW YORK (Reuters Health) - Opioid modulation with the combination of buprenorphine and samidorphan (ALKS 5461) improves symptoms in patients whose depression has not responded adequately to antidepressant treatment, researchers report.

"If the findings are confirmed in phase 3 studies, ALKS 5461 could be used as an augmenting agent in patients not responding to standard antidepressant therapies as an alternative to the atypical antipsychotic agents currently approved for the treatment of this population," Dr. Maurizio Fava, from Massachusetts General Hospital and Harvard Medical School, Boston, told Reuters Health by email.

Buprenorphine is a mu- and kappa-opioid partial agonist, and samidorphan blocks the mu agonist effects of buprenorphine associated with its abuse and addictive potential. A growing body of evidence implicates dysregulation of the endogenous mu- and kappa-opioid system in mood disorders.

Dr. Fava and colleagues at 31 sites in the U.S. used a sequential parallel comparison design to investigate the efficacy of buprenorphine/samidorphan (2 mg/2 mg or 8 mg/8 mg) in 142 patients with major depression inadequately responsive to antidepressant therapy.

At the end of four weeks of treatment, patients in the ALKS 5461 2 mg/2 mg group showed significantly greater improvements in Hamilton Depression Rating Scale (HAM-D), Montgomery-Asberg Depression Rating Scale (MADRS), and Clinical Global Impression severity scores, compared with patients in the placebo group. The ALKS 5461 8 mg/8 mg group showed smaller, nonsignificant improvements.

"The overall effect sizes for the 2/2 dosage were 0.50 for HAM-D and 0.54 for MADRS," the researchers noted. "The result compares favorably with results from a meta-analysis of 14 studies with atypical antipsychotics as adjunctive therapy for major depression, with reported effect sizes of 0.35 to 0.48 for individual drugs."

Treatment response rates according to HAM-D and MADRS (at least 50% reduction in scores) were highest with ALKS 5461 2 mg/2 mg treatment group, according to the February 12 onlinereport in the American Journal of Psychiatry.

Two patients (1.6%) in the placebo group and 17 patients (19.3%) in the ALKS 5461 groups discontinued because of treatment-emergent adverse events, but there was no evidence of opioid withdrawal in any patient.

"When depressed patients do not respond to standard monoamine-based therapies for depression, consider the use of an augmenting agent that modulates other systems, such as the opioid one," Dr. Fava concluded.

Dr. Jeffrey F. Scherrer, from Saint Louis University School of Medicine, St. Louis, Missouri, recently examined the association between opioid use and increased depression rates. He told Reuters Health by email, "Our analysis of opioid use and depression did not include buprenorphine among the opioid exposure variable. Therefore, it is difficult to extrapolate our results to a trial of buprenorphine/samidorphan and major depression."

"As the authors noted, the clinical trial was of short duration and the risks of depression that we have observed appears to be greatest among those patients remaining on opioids for more than 90 days," he explained. "Additional work is currently being done to determine if some opioid medications have a greater depressogenic effect than others, which further limits direct comparison of our findings to the current study."

"I will say that it is unlikely for oxycodone, codeine, and hydrocodone (which together account for more than 90% of prescribed opioids) would help depressed patients and be more likely to worsen their depression with chronic treatment," Dr. Scherrer concluded.

Alkermes sponsored the trial, employed seven coauthors, and had various relationships with the other four coauthors.

NEW YORK (Reuters Health) - Opioid modulation with the combination of buprenorphine and samidorphan (ALKS 5461) improves symptoms in patients whose depression has not responded adequately to antidepressant treatment, researchers report.

"If the findings are confirmed in phase 3 studies, ALKS 5461 could be used as an augmenting agent in patients not responding to standard antidepressant therapies as an alternative to the atypical antipsychotic agents currently approved for the treatment of this population," Dr. Maurizio Fava, from Massachusetts General Hospital and Harvard Medical School, Boston, told Reuters Health by email.

Buprenorphine is a mu- and kappa-opioid partial agonist, and samidorphan blocks the mu agonist effects of buprenorphine associated with its abuse and addictive potential. A growing body of evidence implicates dysregulation of the endogenous mu- and kappa-opioid system in mood disorders.

Dr. Fava and colleagues at 31 sites in the U.S. used a sequential parallel comparison design to investigate the efficacy of buprenorphine/samidorphan (2 mg/2 mg or 8 mg/8 mg) in 142 patients with major depression inadequately responsive to antidepressant therapy.

At the end of four weeks of treatment, patients in the ALKS 5461 2 mg/2 mg group showed significantly greater improvements in Hamilton Depression Rating Scale (HAM-D), Montgomery-Asberg Depression Rating Scale (MADRS), and Clinical Global Impression severity scores, compared with patients in the placebo group. The ALKS 5461 8 mg/8 mg group showed smaller, nonsignificant improvements.

"The overall effect sizes for the 2/2 dosage were 0.50 for HAM-D and 0.54 for MADRS," the researchers noted. "The result compares favorably with results from a meta-analysis of 14 studies with atypical antipsychotics as adjunctive therapy for major depression, with reported effect sizes of 0.35 to 0.48 for individual drugs."

Treatment response rates according to HAM-D and MADRS (at least 50% reduction in scores) were highest with ALKS 5461 2 mg/2 mg treatment group, according to the February 12 onlinereport in the American Journal of Psychiatry.

Two patients (1.6%) in the placebo group and 17 patients (19.3%) in the ALKS 5461 groups discontinued because of treatment-emergent adverse events, but there was no evidence of opioid withdrawal in any patient.

"When depressed patients do not respond to standard monoamine-based therapies for depression, consider the use of an augmenting agent that modulates other systems, such as the opioid one," Dr. Fava concluded.

Dr. Jeffrey F. Scherrer, from Saint Louis University School of Medicine, St. Louis, Missouri, recently examined the association between opioid use and increased depression rates. He told Reuters Health by email, "Our analysis of opioid use and depression did not include buprenorphine among the opioid exposure variable. Therefore, it is difficult to extrapolate our results to a trial of buprenorphine/samidorphan and major depression."

"As the authors noted, the clinical trial was of short duration and the risks of depression that we have observed appears to be greatest among those patients remaining on opioids for more than 90 days," he explained. "Additional work is currently being done to determine if some opioid medications have a greater depressogenic effect than others, which further limits direct comparison of our findings to the current study."

"I will say that it is unlikely for oxycodone, codeine, and hydrocodone (which together account for more than 90% of prescribed opioids) would help depressed patients and be more likely to worsen their depression with chronic treatment," Dr. Scherrer concluded.

Alkermes sponsored the trial, employed seven coauthors, and had various relationships with the other four coauthors.