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Early Palliative Care Can Save Money
Clinical question: Does time to consult after admission change the effect palliative care consultation has on cost of care?
Background: Studies have shown that early palliative care involvement improves quality of life and survival among cancer patients while reducing the cost of care. Little is known about the optimal timing of palliative care consultation and its effect on cost.
Study design: Prospective, observational study.
Setting: Multi-site, high-volume, tertiary care hospitals with established palliative care teams.
Synopsis: Clinical and cost data were collected for 969 adult patients with advanced cancer admitted to the five participating hospitals. Among those, 256 patients received palliative care consultation and 713 received usual care. Subsamples were created based on time to consultation after admission.
The study found that earlier consultation yielded larger effects on cost savings. There was a 24% reduction in total cost if consultation occurred within two days (95% CI, -$3,438 to -$1,122; P<0.001), with estimated savings of $2,280. For consultation within six days of admission, there was a $1,312 savings (95% CI, -$2,568 to -$ 1,122; P<0.04), consistent with a 14% reduction in total cost.
There are notable limitations to this study. Half of eligible patients were excluded due to incomplete data collection, resulting in a small sample size. Further, these results can be generalized only to inpatients with advanced cancer.
Bottom line: Reducing the time to consultation with palliative care increases cost savings. In advanced cancer patients, a 24% reduction in total costs was realized for consultation within two days following admission.
Citation: May P, Garrido MM, Cassel JB, et al. Prospective cohort study of hospital palliative care teams for inpatients with advanced cancer: earlier consultation is associated with larger cost-saving effect. J Clin Oncol. 2015;33(25):2745-2752.
Clinical question: Does time to consult after admission change the effect palliative care consultation has on cost of care?
Background: Studies have shown that early palliative care involvement improves quality of life and survival among cancer patients while reducing the cost of care. Little is known about the optimal timing of palliative care consultation and its effect on cost.
Study design: Prospective, observational study.
Setting: Multi-site, high-volume, tertiary care hospitals with established palliative care teams.
Synopsis: Clinical and cost data were collected for 969 adult patients with advanced cancer admitted to the five participating hospitals. Among those, 256 patients received palliative care consultation and 713 received usual care. Subsamples were created based on time to consultation after admission.
The study found that earlier consultation yielded larger effects on cost savings. There was a 24% reduction in total cost if consultation occurred within two days (95% CI, -$3,438 to -$1,122; P<0.001), with estimated savings of $2,280. For consultation within six days of admission, there was a $1,312 savings (95% CI, -$2,568 to -$ 1,122; P<0.04), consistent with a 14% reduction in total cost.
There are notable limitations to this study. Half of eligible patients were excluded due to incomplete data collection, resulting in a small sample size. Further, these results can be generalized only to inpatients with advanced cancer.
Bottom line: Reducing the time to consultation with palliative care increases cost savings. In advanced cancer patients, a 24% reduction in total costs was realized for consultation within two days following admission.
Citation: May P, Garrido MM, Cassel JB, et al. Prospective cohort study of hospital palliative care teams for inpatients with advanced cancer: earlier consultation is associated with larger cost-saving effect. J Clin Oncol. 2015;33(25):2745-2752.
Clinical question: Does time to consult after admission change the effect palliative care consultation has on cost of care?
Background: Studies have shown that early palliative care involvement improves quality of life and survival among cancer patients while reducing the cost of care. Little is known about the optimal timing of palliative care consultation and its effect on cost.
Study design: Prospective, observational study.
Setting: Multi-site, high-volume, tertiary care hospitals with established palliative care teams.
Synopsis: Clinical and cost data were collected for 969 adult patients with advanced cancer admitted to the five participating hospitals. Among those, 256 patients received palliative care consultation and 713 received usual care. Subsamples were created based on time to consultation after admission.
The study found that earlier consultation yielded larger effects on cost savings. There was a 24% reduction in total cost if consultation occurred within two days (95% CI, -$3,438 to -$1,122; P<0.001), with estimated savings of $2,280. For consultation within six days of admission, there was a $1,312 savings (95% CI, -$2,568 to -$ 1,122; P<0.04), consistent with a 14% reduction in total cost.
There are notable limitations to this study. Half of eligible patients were excluded due to incomplete data collection, resulting in a small sample size. Further, these results can be generalized only to inpatients with advanced cancer.
Bottom line: Reducing the time to consultation with palliative care increases cost savings. In advanced cancer patients, a 24% reduction in total costs was realized for consultation within two days following admission.
Citation: May P, Garrido MM, Cassel JB, et al. Prospective cohort study of hospital palliative care teams for inpatients with advanced cancer: earlier consultation is associated with larger cost-saving effect. J Clin Oncol. 2015;33(25):2745-2752.
Changes to Healthcare that Hospitalists Should Expect in 2016
On the heels of last year’s repeal of the sustainable growth rate (SGR) formula, 2016 promises to be a year of significant changes for the healthcare system. These changes will require providers to focus not just on the immediate pressures and requirements coming from Medicare, of which there are many, but also to look down the road to how things will change in the coming years.
The final year of reporting on quality measures for the Physician Quality Reporting System (PQRS) is 2016, with performance impacting Medicare payments in 2018. Reporting on quality measures doesn’t end there, however. The Medicare Access and CHIP Reauthorization Act (MACRA) repealed the SGR and created two new pathways for pay-for-performance for physicians and most other providers: the Merit-based Incentive Payment System (MIPS) and alternative payment models. After this year, reporting quality measures becomes one component of the MIPS, a program similar to hospital value-based purchasing, but designed for providers.
Quality measures are here to stay. They form the backbone for evaluating whether healthcare is of value. Under the MIPS, quality measures are combined with cost measures, meaningful use, and clinical performance improvement activities to create an aggregate score for providers. That score will be used to determine payment adjustments for providers starting in 2019.
Also in 2016, the Centers for Medicare and Medicaid Services (CMS) will lay the foundation for the MIPS. It is a completely new program, and although it will build on elements of existing programs like PQRS, meaningful use, and the physician value-based payment modifier, its structure and ramifications are ultimately unknown. CMS has indicated its intention to issue the regulatory backbone of MIPS in just a few months. These regulations will be the new reality of Medicare’s fee-for-service for the foreseeable future.
The ramifications of MIPS cannot be understated. It will apply an adjustment based on performance on all Medicare Part B payments. That adjustment starts at +/- 4.0% in 2019 and rises to +/- 9.0% by 2022, a number that is not as far off as it seems based on how these programs operate.
SHM expects many of the current PQRS policies to be continued under MIPS, which means, unfortunately, that many of the challenges facing hospitalists will continue. Hospitalists do not have many measures to report on; most measures are developed for outpatient practices, are simply not reflective of the variability of hospitalist practice, and, even if specified for inpatient reporting, are not clinically relevant.
To meet the needs of hospitalists, SHM will advocate strongly for CMS to develop more flexible and relevant reporting options. We will work to ensure that hospitalists are not structurally disadvantaged by the policies set in place.
Given these upcoming changes, it is as important as ever for you to stay engaged and informed about the policy changes coming down the road. It might be just the start of the year, but already there’s a lot of critical work to do. To get involved and remain apprised of the changes, join SHM’s grassroots network at www.hospitalmedicine.org/grassroots. TH
Joshua Lapps is SHM’s government relations manager.
On the heels of last year’s repeal of the sustainable growth rate (SGR) formula, 2016 promises to be a year of significant changes for the healthcare system. These changes will require providers to focus not just on the immediate pressures and requirements coming from Medicare, of which there are many, but also to look down the road to how things will change in the coming years.
The final year of reporting on quality measures for the Physician Quality Reporting System (PQRS) is 2016, with performance impacting Medicare payments in 2018. Reporting on quality measures doesn’t end there, however. The Medicare Access and CHIP Reauthorization Act (MACRA) repealed the SGR and created two new pathways for pay-for-performance for physicians and most other providers: the Merit-based Incentive Payment System (MIPS) and alternative payment models. After this year, reporting quality measures becomes one component of the MIPS, a program similar to hospital value-based purchasing, but designed for providers.
Quality measures are here to stay. They form the backbone for evaluating whether healthcare is of value. Under the MIPS, quality measures are combined with cost measures, meaningful use, and clinical performance improvement activities to create an aggregate score for providers. That score will be used to determine payment adjustments for providers starting in 2019.
Also in 2016, the Centers for Medicare and Medicaid Services (CMS) will lay the foundation for the MIPS. It is a completely new program, and although it will build on elements of existing programs like PQRS, meaningful use, and the physician value-based payment modifier, its structure and ramifications are ultimately unknown. CMS has indicated its intention to issue the regulatory backbone of MIPS in just a few months. These regulations will be the new reality of Medicare’s fee-for-service for the foreseeable future.
The ramifications of MIPS cannot be understated. It will apply an adjustment based on performance on all Medicare Part B payments. That adjustment starts at +/- 4.0% in 2019 and rises to +/- 9.0% by 2022, a number that is not as far off as it seems based on how these programs operate.
SHM expects many of the current PQRS policies to be continued under MIPS, which means, unfortunately, that many of the challenges facing hospitalists will continue. Hospitalists do not have many measures to report on; most measures are developed for outpatient practices, are simply not reflective of the variability of hospitalist practice, and, even if specified for inpatient reporting, are not clinically relevant.
To meet the needs of hospitalists, SHM will advocate strongly for CMS to develop more flexible and relevant reporting options. We will work to ensure that hospitalists are not structurally disadvantaged by the policies set in place.
Given these upcoming changes, it is as important as ever for you to stay engaged and informed about the policy changes coming down the road. It might be just the start of the year, but already there’s a lot of critical work to do. To get involved and remain apprised of the changes, join SHM’s grassroots network at www.hospitalmedicine.org/grassroots. TH
Joshua Lapps is SHM’s government relations manager.
On the heels of last year’s repeal of the sustainable growth rate (SGR) formula, 2016 promises to be a year of significant changes for the healthcare system. These changes will require providers to focus not just on the immediate pressures and requirements coming from Medicare, of which there are many, but also to look down the road to how things will change in the coming years.
The final year of reporting on quality measures for the Physician Quality Reporting System (PQRS) is 2016, with performance impacting Medicare payments in 2018. Reporting on quality measures doesn’t end there, however. The Medicare Access and CHIP Reauthorization Act (MACRA) repealed the SGR and created two new pathways for pay-for-performance for physicians and most other providers: the Merit-based Incentive Payment System (MIPS) and alternative payment models. After this year, reporting quality measures becomes one component of the MIPS, a program similar to hospital value-based purchasing, but designed for providers.
Quality measures are here to stay. They form the backbone for evaluating whether healthcare is of value. Under the MIPS, quality measures are combined with cost measures, meaningful use, and clinical performance improvement activities to create an aggregate score for providers. That score will be used to determine payment adjustments for providers starting in 2019.
Also in 2016, the Centers for Medicare and Medicaid Services (CMS) will lay the foundation for the MIPS. It is a completely new program, and although it will build on elements of existing programs like PQRS, meaningful use, and the physician value-based payment modifier, its structure and ramifications are ultimately unknown. CMS has indicated its intention to issue the regulatory backbone of MIPS in just a few months. These regulations will be the new reality of Medicare’s fee-for-service for the foreseeable future.
The ramifications of MIPS cannot be understated. It will apply an adjustment based on performance on all Medicare Part B payments. That adjustment starts at +/- 4.0% in 2019 and rises to +/- 9.0% by 2022, a number that is not as far off as it seems based on how these programs operate.
SHM expects many of the current PQRS policies to be continued under MIPS, which means, unfortunately, that many of the challenges facing hospitalists will continue. Hospitalists do not have many measures to report on; most measures are developed for outpatient practices, are simply not reflective of the variability of hospitalist practice, and, even if specified for inpatient reporting, are not clinically relevant.
To meet the needs of hospitalists, SHM will advocate strongly for CMS to develop more flexible and relevant reporting options. We will work to ensure that hospitalists are not structurally disadvantaged by the policies set in place.
Given these upcoming changes, it is as important as ever for you to stay engaged and informed about the policy changes coming down the road. It might be just the start of the year, but already there’s a lot of critical work to do. To get involved and remain apprised of the changes, join SHM’s grassroots network at www.hospitalmedicine.org/grassroots. TH
Joshua Lapps is SHM’s government relations manager.
New SHM Members – January 2016
S. Godfrey, Alabama
W. Mohamed, MD, Alabama
S. Paladugu, MBBS, Alabama
E. Razzouk, Alabama
S. Bommena, MD, Arizona
L. Ledbetter, NP, Arizona
R. Nambusi, MD, Arkansas
S. Asarch, California
J. Barber, California
M. Bikhchandani, California
B. Boesch, DO, California
C. Brown, California
A. Bui, California
E. Collier, California
L. Demyan, California
S. Dowlatshahi, California
M. Edmunds, California
A. Eniasivam, MD, California
Z. Fernandez, California
S. George, MD, California
E. Granflor, ACNP, MSN, RN, California
V. Guitierrez, California
M. Incze, California
B. Jones-Linares, California
S. Judon, California
L. Khuu, MD, California
T. Kim, MD, California
A. Lakhanpal, California
B. Lee, California
E. Li, California
E. Liaw, California
V. Lieu, California
S. Lim, California
B. Lin, California
B. Lizarraga, California
J. Martinez-Cuellar, MD, California
M. Militante-Miller, DO, California
H. Montoya, California
D. Moon, California
L. Mukdad, California
N. Nardoni, California
K. Nguyen, California
B. Ramirez, California
R. Ramos, California
A. Reyes, California
W. Schlesinger, California
B. Scott, California
S. Singh, DO, California
C. Su, California
A. Tavakoli, California
O. Viramontes, California
J. Wassei, MD, California
R. Weiss, MD, California
J. Yuan, MD, California
W. Zellalem, DO, California
Y. Zheng, California
P. Filipowski, MD, Colorado
T. Guns, BHA, Colorado
A. Koch, DO, Colorado
N. Matthews, MD, Colorado
G. McGuire, MD, Colorado
M. Prakash, MBBS, Colorado
L. Stiff, MD, Colorado
J. Garcia, MD, Connecticut
L. Haut, Connecticut
O. Aly, MD, Washington, D.C.
C. Cole, MBA, Washington, D.C.
K. Allen, DO, Florida
S. Andrews, ANP, MS, Florida
G. Clayton, MD, Florida
P. Dubon, MD, Florida
S. Jadonath, MD, Florida
F. Keen, FACP, MD, Florida
A. Khanna, MD, Florida
J. Morrison, MD, PhD, Florida
K. Myint, MBBS, Florida
C. Riccard, MD, Florida
P. Russoniello, ARNP, RN, Florida
L. Staat, ARNP, Florida
K. Tamar, FACS, Florida
R. Torres, MD, Florida
M. Klimenko, MD, Georgia
S. Kommidi, MD, Georgia
H. Patel, MD, Georgia
T. Agni, Illinois
O. Al-Heeti, MD, Illinois
M. Allen, Illinois
C. Brines, Illinois
C. Campbell, Illinois
J. Cho, Illinois
A. Cordasco, Illinois
K. Cramer, Illinois
K. Crawford, Illinois
L. Crawford, Illinois
J. Dale, Illinois
R. Davidov, Illinois
O. Doolittle, Illinois
A. Fuller, Illinois
L. Garland, MD, Illinois
S. Godbois, Illinois
E. Gonzales, Illinois
S. Gupta, MD, Illinois
R. Hameeduddin, DO, Illinois
K. Hayes, Illinois
C. Hill, Illinois
M. Jackson, Illinois
S. Jackson, Illinois
H. Jang, Illinois
M. Keegan, Illinois
E. Kimmie, Illinois
T. Lombardo, Illinois
S. McGowan, Illinois
M. Megaly, Illinois
A. Morker, Illinois
L. Moyar, Illinois
V. Patel, Illinois
C. Pena, Illinois
C. Pinotti, Illinois
W. Poisson, Illinois
K. Puleo, Illinois
R. Schmidgall, Illinois
B. Segel, MD, Illinois
S. Teshale, MD, Illinois
N. Velasquez, Illinois
S. Yeom, Illinois
M. Deb Roy, MD, Indiana
N. Delecaris, MD, Indiana
J. Gilbert, MD, Indiana
M. Ali, Iowa
S. Patel, MD, Kentucky
H. Shah, DO, Kentucky
S. Abraham, MD, Louisiana
M. Bergstedt, MD, Louisiana
J. Burtch, Louisiana
S. Chaney, MD, Louisiana
P. Karam, Louisiana
D. Kim, Louisiana
J. Leong, Louisiana
A. Sheeder, MD, Louisiana
C. Yeh, Louisiana
M. Cunanan-Bush, Maryland
K. Gottlieb, MD, MBA, MS, Maryland
T. Halley, FAAP, Maryland
E. Sholder, PA-C, Maryland
S. Sumner, DO, Maryland
A. Diranian, PA-C, Massachusetts
M. Hunt, DO, Massachusetts
S. Sasidharan, Massachusetts
A. Abdulrazzak, MD, FACP, Michigan
M. Antonishen, Michigan
A. Dhaliwal, MD, Michigan
A. Drummond, MD, Michigan
K. Fitzgerald, MD, Michigan
J. Greenberg, MD, Michigan
C. Lang, MD, Michigan
S. McGinnis, DO, Michigan
L. McMann, Michigan
A. Uwaje, FACP, MD, Michigan
E. Wisniewski, MSN, RN, Michigan
J. Benson, DO, Minnesota
V. Chaudhary, MD, Minnesota
T. Wood, Minnesota
C. Yarke, MD, Minnesota
D. Phillippi, MD, Mississippi
D. Loa, Missouri
J. Loa, Missouri
N. Patel, MD, Missouri
E. Sauer, Missouri
K. Tompkins, MD, FAAP, Missouri
J. Price, FAAFP, Montana
J. Codjoe, MD, New Jersey
I. Khan, MD, New Jersey
E. Merrill, MD, New Jersey
S. Park, DO, New Jersey
T. Ronan, MD, New Mexico
N. Varvaresou, ACNP, New Mexico
E. Ahn, MD, New York
S. Anandan, New York
D. Buff, MD, New York
B. Kranitzky, MD, New York
E. Levine, MHS, MD, New York
J. Noworyta, PA-C, New York
M. Padial, New York
J. Tucker, PA-C, New York
A. Vien, New York
J. DeCoster, MD, MPH, North Carolina
P. Gambrell, NP-C, North Carolina
D. Shah, NP, North Carolina
L. Tlhabano, MD, North Carolina
O. Aduroja, MD, Ohio
A. Ahsan, MD, Ohio
A. Belagavi, Ohio
R. Carletti, Ohio
C. Cox, RN, BSN, Ohio
G. Farkas, Ohio
M. Lileas, MD, DO, FACP, Ohio
A. Lopez, MD, Ohio
S. Mall, Ohio
A. Moren, MD, Ohio
B. Sanaullah, MD, MBBS, Ohio
A. Singh, MBBS, MD, Ohio
A. Thakur, MBBS, Ohio
T. Klimenko, ACNP, Oklahoma
L. Van Dyke, ACNP, Oklahoma
K. Gandhi, Oregon
R. Petersen, Oregon
J. Pruett, MD, Oregon
C. Cobb, MSN, NP, CRNP, FNP-C, Pennsylvania
J. Hickland, Pennsylvania
O. Kufile, MD, Pennsylvania
E. McCullough, MPH, PA-C, Pennsylvania
M. McFall, Pennsylvania
S. Nazir, Pennsylvania
A. Puri, MD, Pennsylvania
W. Romeo, MS, Pennsylvania
J. Gelzhiser, MD, Rhode Island
S. Kim, BA, Rhode Island
K. Cooley, South Carolina
J. Katchman, South Carolina
T. Phillips, South Carolina
J. Oakley, PA, South Dakota
J. Douglass, DO, Tennessee
B. Herron, Tennessee
M. McCain, LPN, FNP, Tennessee
K. Zaman, MD, Tennessee
R. Desai, DO, Texas
P. LeGros, Texas
O. Nguyen, MS, Texas
S. Papineni, MD, Texas
B. Rhinehart, PA-C, Texas
C. Szych, MD, Texas
D. Allred, APRN, Utah
G. Price, Utah
K. Leonard, MD, FAAP, Vermont
D. Rand, DO, Vermont
G. Cabrera, MD, MBA, Virginia
M. Stanton, PA-C, Virginia
J. Voss, Virginia
J. Cameron, MD, Washington
K. Chaganur, MBBS, Washington
G. Dalmacion, MD, Washington
M. Lo, Washington
M. Mahal, BS, MD, Washington
D. Newton, MD, Washington
H. Bertelson, Wisconsin
E. Kitchin, MD, Wisconsin
S. Patel, MD, Wisconsin
E. Yanke, MD, Wisconsin
S. Negrete, BSC, CCFP, MD, Canada
C. Chu, MBBS, MRCP, China
J. Chan, China
N. Pillai, MBBS, MACP, Malaysia
J. Gonzalez Moreno, MD, Mexico
S. Godfrey, Alabama
W. Mohamed, MD, Alabama
S. Paladugu, MBBS, Alabama
E. Razzouk, Alabama
S. Bommena, MD, Arizona
L. Ledbetter, NP, Arizona
R. Nambusi, MD, Arkansas
S. Asarch, California
J. Barber, California
M. Bikhchandani, California
B. Boesch, DO, California
C. Brown, California
A. Bui, California
E. Collier, California
L. Demyan, California
S. Dowlatshahi, California
M. Edmunds, California
A. Eniasivam, MD, California
Z. Fernandez, California
S. George, MD, California
E. Granflor, ACNP, MSN, RN, California
V. Guitierrez, California
M. Incze, California
B. Jones-Linares, California
S. Judon, California
L. Khuu, MD, California
T. Kim, MD, California
A. Lakhanpal, California
B. Lee, California
E. Li, California
E. Liaw, California
V. Lieu, California
S. Lim, California
B. Lin, California
B. Lizarraga, California
J. Martinez-Cuellar, MD, California
M. Militante-Miller, DO, California
H. Montoya, California
D. Moon, California
L. Mukdad, California
N. Nardoni, California
K. Nguyen, California
B. Ramirez, California
R. Ramos, California
A. Reyes, California
W. Schlesinger, California
B. Scott, California
S. Singh, DO, California
C. Su, California
A. Tavakoli, California
O. Viramontes, California
J. Wassei, MD, California
R. Weiss, MD, California
J. Yuan, MD, California
W. Zellalem, DO, California
Y. Zheng, California
P. Filipowski, MD, Colorado
T. Guns, BHA, Colorado
A. Koch, DO, Colorado
N. Matthews, MD, Colorado
G. McGuire, MD, Colorado
M. Prakash, MBBS, Colorado
L. Stiff, MD, Colorado
J. Garcia, MD, Connecticut
L. Haut, Connecticut
O. Aly, MD, Washington, D.C.
C. Cole, MBA, Washington, D.C.
K. Allen, DO, Florida
S. Andrews, ANP, MS, Florida
G. Clayton, MD, Florida
P. Dubon, MD, Florida
S. Jadonath, MD, Florida
F. Keen, FACP, MD, Florida
A. Khanna, MD, Florida
J. Morrison, MD, PhD, Florida
K. Myint, MBBS, Florida
C. Riccard, MD, Florida
P. Russoniello, ARNP, RN, Florida
L. Staat, ARNP, Florida
K. Tamar, FACS, Florida
R. Torres, MD, Florida
M. Klimenko, MD, Georgia
S. Kommidi, MD, Georgia
H. Patel, MD, Georgia
T. Agni, Illinois
O. Al-Heeti, MD, Illinois
M. Allen, Illinois
C. Brines, Illinois
C. Campbell, Illinois
J. Cho, Illinois
A. Cordasco, Illinois
K. Cramer, Illinois
K. Crawford, Illinois
L. Crawford, Illinois
J. Dale, Illinois
R. Davidov, Illinois
O. Doolittle, Illinois
A. Fuller, Illinois
L. Garland, MD, Illinois
S. Godbois, Illinois
E. Gonzales, Illinois
S. Gupta, MD, Illinois
R. Hameeduddin, DO, Illinois
K. Hayes, Illinois
C. Hill, Illinois
M. Jackson, Illinois
S. Jackson, Illinois
H. Jang, Illinois
M. Keegan, Illinois
E. Kimmie, Illinois
T. Lombardo, Illinois
S. McGowan, Illinois
M. Megaly, Illinois
A. Morker, Illinois
L. Moyar, Illinois
V. Patel, Illinois
C. Pena, Illinois
C. Pinotti, Illinois
W. Poisson, Illinois
K. Puleo, Illinois
R. Schmidgall, Illinois
B. Segel, MD, Illinois
S. Teshale, MD, Illinois
N. Velasquez, Illinois
S. Yeom, Illinois
M. Deb Roy, MD, Indiana
N. Delecaris, MD, Indiana
J. Gilbert, MD, Indiana
M. Ali, Iowa
S. Patel, MD, Kentucky
H. Shah, DO, Kentucky
S. Abraham, MD, Louisiana
M. Bergstedt, MD, Louisiana
J. Burtch, Louisiana
S. Chaney, MD, Louisiana
P. Karam, Louisiana
D. Kim, Louisiana
J. Leong, Louisiana
A. Sheeder, MD, Louisiana
C. Yeh, Louisiana
M. Cunanan-Bush, Maryland
K. Gottlieb, MD, MBA, MS, Maryland
T. Halley, FAAP, Maryland
E. Sholder, PA-C, Maryland
S. Sumner, DO, Maryland
A. Diranian, PA-C, Massachusetts
M. Hunt, DO, Massachusetts
S. Sasidharan, Massachusetts
A. Abdulrazzak, MD, FACP, Michigan
M. Antonishen, Michigan
A. Dhaliwal, MD, Michigan
A. Drummond, MD, Michigan
K. Fitzgerald, MD, Michigan
J. Greenberg, MD, Michigan
C. Lang, MD, Michigan
S. McGinnis, DO, Michigan
L. McMann, Michigan
A. Uwaje, FACP, MD, Michigan
E. Wisniewski, MSN, RN, Michigan
J. Benson, DO, Minnesota
V. Chaudhary, MD, Minnesota
T. Wood, Minnesota
C. Yarke, MD, Minnesota
D. Phillippi, MD, Mississippi
D. Loa, Missouri
J. Loa, Missouri
N. Patel, MD, Missouri
E. Sauer, Missouri
K. Tompkins, MD, FAAP, Missouri
J. Price, FAAFP, Montana
J. Codjoe, MD, New Jersey
I. Khan, MD, New Jersey
E. Merrill, MD, New Jersey
S. Park, DO, New Jersey
T. Ronan, MD, New Mexico
N. Varvaresou, ACNP, New Mexico
E. Ahn, MD, New York
S. Anandan, New York
D. Buff, MD, New York
B. Kranitzky, MD, New York
E. Levine, MHS, MD, New York
J. Noworyta, PA-C, New York
M. Padial, New York
J. Tucker, PA-C, New York
A. Vien, New York
J. DeCoster, MD, MPH, North Carolina
P. Gambrell, NP-C, North Carolina
D. Shah, NP, North Carolina
L. Tlhabano, MD, North Carolina
O. Aduroja, MD, Ohio
A. Ahsan, MD, Ohio
A. Belagavi, Ohio
R. Carletti, Ohio
C. Cox, RN, BSN, Ohio
G. Farkas, Ohio
M. Lileas, MD, DO, FACP, Ohio
A. Lopez, MD, Ohio
S. Mall, Ohio
A. Moren, MD, Ohio
B. Sanaullah, MD, MBBS, Ohio
A. Singh, MBBS, MD, Ohio
A. Thakur, MBBS, Ohio
T. Klimenko, ACNP, Oklahoma
L. Van Dyke, ACNP, Oklahoma
K. Gandhi, Oregon
R. Petersen, Oregon
J. Pruett, MD, Oregon
C. Cobb, MSN, NP, CRNP, FNP-C, Pennsylvania
J. Hickland, Pennsylvania
O. Kufile, MD, Pennsylvania
E. McCullough, MPH, PA-C, Pennsylvania
M. McFall, Pennsylvania
S. Nazir, Pennsylvania
A. Puri, MD, Pennsylvania
W. Romeo, MS, Pennsylvania
J. Gelzhiser, MD, Rhode Island
S. Kim, BA, Rhode Island
K. Cooley, South Carolina
J. Katchman, South Carolina
T. Phillips, South Carolina
J. Oakley, PA, South Dakota
J. Douglass, DO, Tennessee
B. Herron, Tennessee
M. McCain, LPN, FNP, Tennessee
K. Zaman, MD, Tennessee
R. Desai, DO, Texas
P. LeGros, Texas
O. Nguyen, MS, Texas
S. Papineni, MD, Texas
B. Rhinehart, PA-C, Texas
C. Szych, MD, Texas
D. Allred, APRN, Utah
G. Price, Utah
K. Leonard, MD, FAAP, Vermont
D. Rand, DO, Vermont
G. Cabrera, MD, MBA, Virginia
M. Stanton, PA-C, Virginia
J. Voss, Virginia
J. Cameron, MD, Washington
K. Chaganur, MBBS, Washington
G. Dalmacion, MD, Washington
M. Lo, Washington
M. Mahal, BS, MD, Washington
D. Newton, MD, Washington
H. Bertelson, Wisconsin
E. Kitchin, MD, Wisconsin
S. Patel, MD, Wisconsin
E. Yanke, MD, Wisconsin
S. Negrete, BSC, CCFP, MD, Canada
C. Chu, MBBS, MRCP, China
J. Chan, China
N. Pillai, MBBS, MACP, Malaysia
J. Gonzalez Moreno, MD, Mexico
S. Godfrey, Alabama
W. Mohamed, MD, Alabama
S. Paladugu, MBBS, Alabama
E. Razzouk, Alabama
S. Bommena, MD, Arizona
L. Ledbetter, NP, Arizona
R. Nambusi, MD, Arkansas
S. Asarch, California
J. Barber, California
M. Bikhchandani, California
B. Boesch, DO, California
C. Brown, California
A. Bui, California
E. Collier, California
L. Demyan, California
S. Dowlatshahi, California
M. Edmunds, California
A. Eniasivam, MD, California
Z. Fernandez, California
S. George, MD, California
E. Granflor, ACNP, MSN, RN, California
V. Guitierrez, California
M. Incze, California
B. Jones-Linares, California
S. Judon, California
L. Khuu, MD, California
T. Kim, MD, California
A. Lakhanpal, California
B. Lee, California
E. Li, California
E. Liaw, California
V. Lieu, California
S. Lim, California
B. Lin, California
B. Lizarraga, California
J. Martinez-Cuellar, MD, California
M. Militante-Miller, DO, California
H. Montoya, California
D. Moon, California
L. Mukdad, California
N. Nardoni, California
K. Nguyen, California
B. Ramirez, California
R. Ramos, California
A. Reyes, California
W. Schlesinger, California
B. Scott, California
S. Singh, DO, California
C. Su, California
A. Tavakoli, California
O. Viramontes, California
J. Wassei, MD, California
R. Weiss, MD, California
J. Yuan, MD, California
W. Zellalem, DO, California
Y. Zheng, California
P. Filipowski, MD, Colorado
T. Guns, BHA, Colorado
A. Koch, DO, Colorado
N. Matthews, MD, Colorado
G. McGuire, MD, Colorado
M. Prakash, MBBS, Colorado
L. Stiff, MD, Colorado
J. Garcia, MD, Connecticut
L. Haut, Connecticut
O. Aly, MD, Washington, D.C.
C. Cole, MBA, Washington, D.C.
K. Allen, DO, Florida
S. Andrews, ANP, MS, Florida
G. Clayton, MD, Florida
P. Dubon, MD, Florida
S. Jadonath, MD, Florida
F. Keen, FACP, MD, Florida
A. Khanna, MD, Florida
J. Morrison, MD, PhD, Florida
K. Myint, MBBS, Florida
C. Riccard, MD, Florida
P. Russoniello, ARNP, RN, Florida
L. Staat, ARNP, Florida
K. Tamar, FACS, Florida
R. Torres, MD, Florida
M. Klimenko, MD, Georgia
S. Kommidi, MD, Georgia
H. Patel, MD, Georgia
T. Agni, Illinois
O. Al-Heeti, MD, Illinois
M. Allen, Illinois
C. Brines, Illinois
C. Campbell, Illinois
J. Cho, Illinois
A. Cordasco, Illinois
K. Cramer, Illinois
K. Crawford, Illinois
L. Crawford, Illinois
J. Dale, Illinois
R. Davidov, Illinois
O. Doolittle, Illinois
A. Fuller, Illinois
L. Garland, MD, Illinois
S. Godbois, Illinois
E. Gonzales, Illinois
S. Gupta, MD, Illinois
R. Hameeduddin, DO, Illinois
K. Hayes, Illinois
C. Hill, Illinois
M. Jackson, Illinois
S. Jackson, Illinois
H. Jang, Illinois
M. Keegan, Illinois
E. Kimmie, Illinois
T. Lombardo, Illinois
S. McGowan, Illinois
M. Megaly, Illinois
A. Morker, Illinois
L. Moyar, Illinois
V. Patel, Illinois
C. Pena, Illinois
C. Pinotti, Illinois
W. Poisson, Illinois
K. Puleo, Illinois
R. Schmidgall, Illinois
B. Segel, MD, Illinois
S. Teshale, MD, Illinois
N. Velasquez, Illinois
S. Yeom, Illinois
M. Deb Roy, MD, Indiana
N. Delecaris, MD, Indiana
J. Gilbert, MD, Indiana
M. Ali, Iowa
S. Patel, MD, Kentucky
H. Shah, DO, Kentucky
S. Abraham, MD, Louisiana
M. Bergstedt, MD, Louisiana
J. Burtch, Louisiana
S. Chaney, MD, Louisiana
P. Karam, Louisiana
D. Kim, Louisiana
J. Leong, Louisiana
A. Sheeder, MD, Louisiana
C. Yeh, Louisiana
M. Cunanan-Bush, Maryland
K. Gottlieb, MD, MBA, MS, Maryland
T. Halley, FAAP, Maryland
E. Sholder, PA-C, Maryland
S. Sumner, DO, Maryland
A. Diranian, PA-C, Massachusetts
M. Hunt, DO, Massachusetts
S. Sasidharan, Massachusetts
A. Abdulrazzak, MD, FACP, Michigan
M. Antonishen, Michigan
A. Dhaliwal, MD, Michigan
A. Drummond, MD, Michigan
K. Fitzgerald, MD, Michigan
J. Greenberg, MD, Michigan
C. Lang, MD, Michigan
S. McGinnis, DO, Michigan
L. McMann, Michigan
A. Uwaje, FACP, MD, Michigan
E. Wisniewski, MSN, RN, Michigan
J. Benson, DO, Minnesota
V. Chaudhary, MD, Minnesota
T. Wood, Minnesota
C. Yarke, MD, Minnesota
D. Phillippi, MD, Mississippi
D. Loa, Missouri
J. Loa, Missouri
N. Patel, MD, Missouri
E. Sauer, Missouri
K. Tompkins, MD, FAAP, Missouri
J. Price, FAAFP, Montana
J. Codjoe, MD, New Jersey
I. Khan, MD, New Jersey
E. Merrill, MD, New Jersey
S. Park, DO, New Jersey
T. Ronan, MD, New Mexico
N. Varvaresou, ACNP, New Mexico
E. Ahn, MD, New York
S. Anandan, New York
D. Buff, MD, New York
B. Kranitzky, MD, New York
E. Levine, MHS, MD, New York
J. Noworyta, PA-C, New York
M. Padial, New York
J. Tucker, PA-C, New York
A. Vien, New York
J. DeCoster, MD, MPH, North Carolina
P. Gambrell, NP-C, North Carolina
D. Shah, NP, North Carolina
L. Tlhabano, MD, North Carolina
O. Aduroja, MD, Ohio
A. Ahsan, MD, Ohio
A. Belagavi, Ohio
R. Carletti, Ohio
C. Cox, RN, BSN, Ohio
G. Farkas, Ohio
M. Lileas, MD, DO, FACP, Ohio
A. Lopez, MD, Ohio
S. Mall, Ohio
A. Moren, MD, Ohio
B. Sanaullah, MD, MBBS, Ohio
A. Singh, MBBS, MD, Ohio
A. Thakur, MBBS, Ohio
T. Klimenko, ACNP, Oklahoma
L. Van Dyke, ACNP, Oklahoma
K. Gandhi, Oregon
R. Petersen, Oregon
J. Pruett, MD, Oregon
C. Cobb, MSN, NP, CRNP, FNP-C, Pennsylvania
J. Hickland, Pennsylvania
O. Kufile, MD, Pennsylvania
E. McCullough, MPH, PA-C, Pennsylvania
M. McFall, Pennsylvania
S. Nazir, Pennsylvania
A. Puri, MD, Pennsylvania
W. Romeo, MS, Pennsylvania
J. Gelzhiser, MD, Rhode Island
S. Kim, BA, Rhode Island
K. Cooley, South Carolina
J. Katchman, South Carolina
T. Phillips, South Carolina
J. Oakley, PA, South Dakota
J. Douglass, DO, Tennessee
B. Herron, Tennessee
M. McCain, LPN, FNP, Tennessee
K. Zaman, MD, Tennessee
R. Desai, DO, Texas
P. LeGros, Texas
O. Nguyen, MS, Texas
S. Papineni, MD, Texas
B. Rhinehart, PA-C, Texas
C. Szych, MD, Texas
D. Allred, APRN, Utah
G. Price, Utah
K. Leonard, MD, FAAP, Vermont
D. Rand, DO, Vermont
G. Cabrera, MD, MBA, Virginia
M. Stanton, PA-C, Virginia
J. Voss, Virginia
J. Cameron, MD, Washington
K. Chaganur, MBBS, Washington
G. Dalmacion, MD, Washington
M. Lo, Washington
M. Mahal, BS, MD, Washington
D. Newton, MD, Washington
H. Bertelson, Wisconsin
E. Kitchin, MD, Wisconsin
S. Patel, MD, Wisconsin
E. Yanke, MD, Wisconsin
S. Negrete, BSC, CCFP, MD, Canada
C. Chu, MBBS, MRCP, China
J. Chan, China
N. Pillai, MBBS, MACP, Malaysia
J. Gonzalez Moreno, MD, Mexico
Parental Perceptions of Nighttime Communication Are Strong Predictors of Patient Experience
Clinical question: How does parental perception of overnight pediatric inpatient care affect the overall patient experience?
Background: Restrictions on resident duty hours have become progressively more stringent as attention to the effects of resident fatigue on patient safety has increased. In 2011, the Accreditation Council for Graduate Medical Education (ACGME) limited total weekly duty hours to 80 and reduced shifts for junior trainees to a maximum of 16 hours. As a result, a majority of teaching hospitals have instituted “night float,” or night team models, for overnight coverage of pediatric inpatients. The rapid adoption of night float inpatient coverage models has raised concerns about training residents in a structure that may not foster patient ownership and may promote shift worker mentality. Although communication between healthcare providers and patients/caregivers is known to be a key driver of patient satisfaction, little is known about the quality of communication overnight in the era of night float teams.
Study design: Prospective cohort study utilizing survey methodology.
Setting: Two general pediatric units at a 395-bed, urban, freestanding children’s teaching hospital.
Synopsis: A randomly selected subset of children (0-17 years) with English-speaking parents/caregivers admitted to two general pediatric units was studied over an 18-month period. Both general pediatric and subspecialty service patients, including adolescent, immunology, hematology, and rheumatology, were included. Researchers administered written surveys on weekday (Monday-Thursday) evenings prior to discharge, and surveys were collected either later that evening or in the morning. The surveys included 29 questions that used a five-point Likert scale to assess communication and experience.
These questions covered the following constructs:
- Parent understanding of the medical plan;
- Parent communication and experience with nighttime doctors;
- Parent communication and experience with nighttime nurses;
- Parent perceptions of nighttime interactions between doctors and nurses; and
- Parent overall experience of care during hospitalization.
An open question addressing whether parents had anything else to share about communication during the hospitalization was included. The primary outcome measure was the so-called “top-box” rating of overall experience of care during the hospitalization (from construct five). This outcome was dichotomous based on whether the parent had given the highest rating or not for all five questions in that construct (either “excellent” or “strongly agree”).
A top-box rating of overall experience of care was found to be associated with high mean construct scores regarding communication and experience with doctors (4.85) and nurses (4.87). Top-box overall experience ratings were also associated with top ratings for coordination between daytime and nighttime nurses and for teamwork between nighttime doctors and nurses. Multivariable analysis showed that parents’ rating of direct communications with doctors and nurses and perceived teamwork and communication between doctors and nurses were significant predictors of top-box overall experience.
Bottom line: Parents’ perceptions of direct communications with nighttime doctors and nurses and their perceived teamwork and communication were strong predictors of overall experience of care during pediatric hospitalization.
Citation: Khan A, Rogers JE, Melvin P, et al. Physician and nurse nighttime communication and parents’ hospital experience. Pediatrics. 2015;136(5):e1249-1258.
Clinical question: How does parental perception of overnight pediatric inpatient care affect the overall patient experience?
Background: Restrictions on resident duty hours have become progressively more stringent as attention to the effects of resident fatigue on patient safety has increased. In 2011, the Accreditation Council for Graduate Medical Education (ACGME) limited total weekly duty hours to 80 and reduced shifts for junior trainees to a maximum of 16 hours. As a result, a majority of teaching hospitals have instituted “night float,” or night team models, for overnight coverage of pediatric inpatients. The rapid adoption of night float inpatient coverage models has raised concerns about training residents in a structure that may not foster patient ownership and may promote shift worker mentality. Although communication between healthcare providers and patients/caregivers is known to be a key driver of patient satisfaction, little is known about the quality of communication overnight in the era of night float teams.
Study design: Prospective cohort study utilizing survey methodology.
Setting: Two general pediatric units at a 395-bed, urban, freestanding children’s teaching hospital.
Synopsis: A randomly selected subset of children (0-17 years) with English-speaking parents/caregivers admitted to two general pediatric units was studied over an 18-month period. Both general pediatric and subspecialty service patients, including adolescent, immunology, hematology, and rheumatology, were included. Researchers administered written surveys on weekday (Monday-Thursday) evenings prior to discharge, and surveys were collected either later that evening or in the morning. The surveys included 29 questions that used a five-point Likert scale to assess communication and experience.
These questions covered the following constructs:
- Parent understanding of the medical plan;
- Parent communication and experience with nighttime doctors;
- Parent communication and experience with nighttime nurses;
- Parent perceptions of nighttime interactions between doctors and nurses; and
- Parent overall experience of care during hospitalization.
An open question addressing whether parents had anything else to share about communication during the hospitalization was included. The primary outcome measure was the so-called “top-box” rating of overall experience of care during the hospitalization (from construct five). This outcome was dichotomous based on whether the parent had given the highest rating or not for all five questions in that construct (either “excellent” or “strongly agree”).
A top-box rating of overall experience of care was found to be associated with high mean construct scores regarding communication and experience with doctors (4.85) and nurses (4.87). Top-box overall experience ratings were also associated with top ratings for coordination between daytime and nighttime nurses and for teamwork between nighttime doctors and nurses. Multivariable analysis showed that parents’ rating of direct communications with doctors and nurses and perceived teamwork and communication between doctors and nurses were significant predictors of top-box overall experience.
Bottom line: Parents’ perceptions of direct communications with nighttime doctors and nurses and their perceived teamwork and communication were strong predictors of overall experience of care during pediatric hospitalization.
Citation: Khan A, Rogers JE, Melvin P, et al. Physician and nurse nighttime communication and parents’ hospital experience. Pediatrics. 2015;136(5):e1249-1258.
Clinical question: How does parental perception of overnight pediatric inpatient care affect the overall patient experience?
Background: Restrictions on resident duty hours have become progressively more stringent as attention to the effects of resident fatigue on patient safety has increased. In 2011, the Accreditation Council for Graduate Medical Education (ACGME) limited total weekly duty hours to 80 and reduced shifts for junior trainees to a maximum of 16 hours. As a result, a majority of teaching hospitals have instituted “night float,” or night team models, for overnight coverage of pediatric inpatients. The rapid adoption of night float inpatient coverage models has raised concerns about training residents in a structure that may not foster patient ownership and may promote shift worker mentality. Although communication between healthcare providers and patients/caregivers is known to be a key driver of patient satisfaction, little is known about the quality of communication overnight in the era of night float teams.
Study design: Prospective cohort study utilizing survey methodology.
Setting: Two general pediatric units at a 395-bed, urban, freestanding children’s teaching hospital.
Synopsis: A randomly selected subset of children (0-17 years) with English-speaking parents/caregivers admitted to two general pediatric units was studied over an 18-month period. Both general pediatric and subspecialty service patients, including adolescent, immunology, hematology, and rheumatology, were included. Researchers administered written surveys on weekday (Monday-Thursday) evenings prior to discharge, and surveys were collected either later that evening or in the morning. The surveys included 29 questions that used a five-point Likert scale to assess communication and experience.
These questions covered the following constructs:
- Parent understanding of the medical plan;
- Parent communication and experience with nighttime doctors;
- Parent communication and experience with nighttime nurses;
- Parent perceptions of nighttime interactions between doctors and nurses; and
- Parent overall experience of care during hospitalization.
An open question addressing whether parents had anything else to share about communication during the hospitalization was included. The primary outcome measure was the so-called “top-box” rating of overall experience of care during the hospitalization (from construct five). This outcome was dichotomous based on whether the parent had given the highest rating or not for all five questions in that construct (either “excellent” or “strongly agree”).
A top-box rating of overall experience of care was found to be associated with high mean construct scores regarding communication and experience with doctors (4.85) and nurses (4.87). Top-box overall experience ratings were also associated with top ratings for coordination between daytime and nighttime nurses and for teamwork between nighttime doctors and nurses. Multivariable analysis showed that parents’ rating of direct communications with doctors and nurses and perceived teamwork and communication between doctors and nurses were significant predictors of top-box overall experience.
Bottom line: Parents’ perceptions of direct communications with nighttime doctors and nurses and their perceived teamwork and communication were strong predictors of overall experience of care during pediatric hospitalization.
Citation: Khan A, Rogers JE, Melvin P, et al. Physician and nurse nighttime communication and parents’ hospital experience. Pediatrics. 2015;136(5):e1249-1258.
Concerns Grow as Top Clinicians Choose Nonclinical Roles
On a spring day a couple of years ago, I met with some internal medicine residents in a “Healthcare Systems Immersion” elective. I was to provide thoughts about the nonclinical portion of my work that I spend consulting with other hospitalist groups.
I asked for their thoughts about whether the ranks of doctors providing direct bedside care were losing too many of the most talented clinicians to nonclinical roles. The most vocal resident was confident that was not the case; these doctors would ultimately have a positive impact on the care of larger numbers of patients through administrative work than through direct patient care.
I wonder if she is right.
Numerous Hospitalists Opt for Nonnclinical Work
It seems like lots of hospitalists are transitioning to nonclinical work. My experience is that most who have administrative or other nonclinical roles continue—for part of their time—to provide direct patient care. But some leave clinical work behind altogether. Some of them are very prominent people in our field, like the top physician at CMS, the current U.S. Surgeon General, and this year’s most influential physician executive as judged by Modern Healthcare. I think it is pretty cool that these people come from our specialty.
I couldn’t find published survey data on the portion of hospitalists, or doctors in any specialty, who have entirely (or almost entirely) nonclinical roles. My impression is that this was a vanishingly small number across all specialties 30 or 40 years ago, but it seems to have increased pretty dramatically in the last 10 years. At the start of my career, few hospitals had a physician in an administrative position. Now it is common.
Physician leadership roles now include information technology (CMIO), quality (CQO), leader of the employed physician group, and hospital CEO (at least two hospitalists I know are in this role). And there are lots of nonclinical roles for doctors outside of hospitals.
Pros, Cons for Healthcare
I’ve had mixed feelings watching many people leave clinical practice. Most of them, like those mentioned above, continue to make important contributions to our healthcare system; they improve the services and care patients receive. Yet it seems like some of the best clinicians are taken from active practice and are difficult to replace.
At the start of my career, the few doctors who left clinical practice for nonclinical work tended to do so late in their careers. Now many make this choice very early in their careers. Of the six or seven residents I met with above, several planned to pursue entirely nonclinical work either immediately upon completing residency or after just a few years of clinical practice. They were at one of the top internal medicine programs in the country and will, presumably, provide direct clinical care to a really small number of patients over their careers.
It makes me wonder if there is a meaningful effect of more talented people having, and exercising, the option to leave clinical practice, resulting in a tilt toward somewhat-less-talented doctors left to treat patients. I hope there is no meaningful effect in this direction, but I’m not sure.
Reasons to Move
My experience is that most doctors who have left clinical work will wax eloquent about how they really loved it and weren’t fleeing it but did so because they wanted to “try something new” or contribute to healthcare in other ways. I’m suspicious that for many of them this isn’t entirely true. Some must have been fleeing it. They were burned out, tired of being on call, and so on, and were eager to find relief from clinical work more than they were “drawn to a new career challenge.” They just don’t want to admit it.
I sometimes think about what several nationally prominent hospitalist leaders have said to me over my career. Not long ago, one said, “Wow. You’re still seeing patients and making rounds? I can’t believe it. You need to find something better.”
This doctor seemed to equate an entire career spent in clinical practice as something done mostly by those who aren’t talented enough to have other options. What a change from 30 or 40 years ago.
Several years ago, in a very moving conversation, another nationally prominent hospitalist leader told me, “It’s all about the patient and how we care for them at the bedside. There’s no better way we can spend our time.”
The Best Career
Within a few years, he left clinical practice entirely, even though he was still mid-career.
I hold in highest esteem hospitalists and other doctors who spend a full career in direct patient care and do it well. At the top of that list is my own dad, who is up there with Osler when it comes to dedicated physicians.
Of course, those who spend most or all of their time in nonclinical work really can make important contributions that help the healthcare system better serve patients, in some cases clearly making a bigger difference for more patients than they could via direct clinical care. We need talented people in both roles, but we also need to always be looking for ways to minimize the numbers of doctors who feel the need to flee a clinical career.
Like many hospitalists, I think about these things a lot when making decisions about my own career. I hope we all have the wisdom to make the best choices for ourselves, and for the patients we set out to serve when we entered medical school. TH
On a spring day a couple of years ago, I met with some internal medicine residents in a “Healthcare Systems Immersion” elective. I was to provide thoughts about the nonclinical portion of my work that I spend consulting with other hospitalist groups.
I asked for their thoughts about whether the ranks of doctors providing direct bedside care were losing too many of the most talented clinicians to nonclinical roles. The most vocal resident was confident that was not the case; these doctors would ultimately have a positive impact on the care of larger numbers of patients through administrative work than through direct patient care.
I wonder if she is right.
Numerous Hospitalists Opt for Nonnclinical Work
It seems like lots of hospitalists are transitioning to nonclinical work. My experience is that most who have administrative or other nonclinical roles continue—for part of their time—to provide direct patient care. But some leave clinical work behind altogether. Some of them are very prominent people in our field, like the top physician at CMS, the current U.S. Surgeon General, and this year’s most influential physician executive as judged by Modern Healthcare. I think it is pretty cool that these people come from our specialty.
I couldn’t find published survey data on the portion of hospitalists, or doctors in any specialty, who have entirely (or almost entirely) nonclinical roles. My impression is that this was a vanishingly small number across all specialties 30 or 40 years ago, but it seems to have increased pretty dramatically in the last 10 years. At the start of my career, few hospitals had a physician in an administrative position. Now it is common.
Physician leadership roles now include information technology (CMIO), quality (CQO), leader of the employed physician group, and hospital CEO (at least two hospitalists I know are in this role). And there are lots of nonclinical roles for doctors outside of hospitals.
Pros, Cons for Healthcare
I’ve had mixed feelings watching many people leave clinical practice. Most of them, like those mentioned above, continue to make important contributions to our healthcare system; they improve the services and care patients receive. Yet it seems like some of the best clinicians are taken from active practice and are difficult to replace.
At the start of my career, the few doctors who left clinical practice for nonclinical work tended to do so late in their careers. Now many make this choice very early in their careers. Of the six or seven residents I met with above, several planned to pursue entirely nonclinical work either immediately upon completing residency or after just a few years of clinical practice. They were at one of the top internal medicine programs in the country and will, presumably, provide direct clinical care to a really small number of patients over their careers.
It makes me wonder if there is a meaningful effect of more talented people having, and exercising, the option to leave clinical practice, resulting in a tilt toward somewhat-less-talented doctors left to treat patients. I hope there is no meaningful effect in this direction, but I’m not sure.
Reasons to Move
My experience is that most doctors who have left clinical work will wax eloquent about how they really loved it and weren’t fleeing it but did so because they wanted to “try something new” or contribute to healthcare in other ways. I’m suspicious that for many of them this isn’t entirely true. Some must have been fleeing it. They were burned out, tired of being on call, and so on, and were eager to find relief from clinical work more than they were “drawn to a new career challenge.” They just don’t want to admit it.
I sometimes think about what several nationally prominent hospitalist leaders have said to me over my career. Not long ago, one said, “Wow. You’re still seeing patients and making rounds? I can’t believe it. You need to find something better.”
This doctor seemed to equate an entire career spent in clinical practice as something done mostly by those who aren’t talented enough to have other options. What a change from 30 or 40 years ago.
Several years ago, in a very moving conversation, another nationally prominent hospitalist leader told me, “It’s all about the patient and how we care for them at the bedside. There’s no better way we can spend our time.”
The Best Career
Within a few years, he left clinical practice entirely, even though he was still mid-career.
I hold in highest esteem hospitalists and other doctors who spend a full career in direct patient care and do it well. At the top of that list is my own dad, who is up there with Osler when it comes to dedicated physicians.
Of course, those who spend most or all of their time in nonclinical work really can make important contributions that help the healthcare system better serve patients, in some cases clearly making a bigger difference for more patients than they could via direct clinical care. We need talented people in both roles, but we also need to always be looking for ways to minimize the numbers of doctors who feel the need to flee a clinical career.
Like many hospitalists, I think about these things a lot when making decisions about my own career. I hope we all have the wisdom to make the best choices for ourselves, and for the patients we set out to serve when we entered medical school. TH
On a spring day a couple of years ago, I met with some internal medicine residents in a “Healthcare Systems Immersion” elective. I was to provide thoughts about the nonclinical portion of my work that I spend consulting with other hospitalist groups.
I asked for their thoughts about whether the ranks of doctors providing direct bedside care were losing too many of the most talented clinicians to nonclinical roles. The most vocal resident was confident that was not the case; these doctors would ultimately have a positive impact on the care of larger numbers of patients through administrative work than through direct patient care.
I wonder if she is right.
Numerous Hospitalists Opt for Nonnclinical Work
It seems like lots of hospitalists are transitioning to nonclinical work. My experience is that most who have administrative or other nonclinical roles continue—for part of their time—to provide direct patient care. But some leave clinical work behind altogether. Some of them are very prominent people in our field, like the top physician at CMS, the current U.S. Surgeon General, and this year’s most influential physician executive as judged by Modern Healthcare. I think it is pretty cool that these people come from our specialty.
I couldn’t find published survey data on the portion of hospitalists, or doctors in any specialty, who have entirely (or almost entirely) nonclinical roles. My impression is that this was a vanishingly small number across all specialties 30 or 40 years ago, but it seems to have increased pretty dramatically in the last 10 years. At the start of my career, few hospitals had a physician in an administrative position. Now it is common.
Physician leadership roles now include information technology (CMIO), quality (CQO), leader of the employed physician group, and hospital CEO (at least two hospitalists I know are in this role). And there are lots of nonclinical roles for doctors outside of hospitals.
Pros, Cons for Healthcare
I’ve had mixed feelings watching many people leave clinical practice. Most of them, like those mentioned above, continue to make important contributions to our healthcare system; they improve the services and care patients receive. Yet it seems like some of the best clinicians are taken from active practice and are difficult to replace.
At the start of my career, the few doctors who left clinical practice for nonclinical work tended to do so late in their careers. Now many make this choice very early in their careers. Of the six or seven residents I met with above, several planned to pursue entirely nonclinical work either immediately upon completing residency or after just a few years of clinical practice. They were at one of the top internal medicine programs in the country and will, presumably, provide direct clinical care to a really small number of patients over their careers.
It makes me wonder if there is a meaningful effect of more talented people having, and exercising, the option to leave clinical practice, resulting in a tilt toward somewhat-less-talented doctors left to treat patients. I hope there is no meaningful effect in this direction, but I’m not sure.
Reasons to Move
My experience is that most doctors who have left clinical work will wax eloquent about how they really loved it and weren’t fleeing it but did so because they wanted to “try something new” or contribute to healthcare in other ways. I’m suspicious that for many of them this isn’t entirely true. Some must have been fleeing it. They were burned out, tired of being on call, and so on, and were eager to find relief from clinical work more than they were “drawn to a new career challenge.” They just don’t want to admit it.
I sometimes think about what several nationally prominent hospitalist leaders have said to me over my career. Not long ago, one said, “Wow. You’re still seeing patients and making rounds? I can’t believe it. You need to find something better.”
This doctor seemed to equate an entire career spent in clinical practice as something done mostly by those who aren’t talented enough to have other options. What a change from 30 or 40 years ago.
Several years ago, in a very moving conversation, another nationally prominent hospitalist leader told me, “It’s all about the patient and how we care for them at the bedside. There’s no better way we can spend our time.”
The Best Career
Within a few years, he left clinical practice entirely, even though he was still mid-career.
I hold in highest esteem hospitalists and other doctors who spend a full career in direct patient care and do it well. At the top of that list is my own dad, who is up there with Osler when it comes to dedicated physicians.
Of course, those who spend most or all of their time in nonclinical work really can make important contributions that help the healthcare system better serve patients, in some cases clearly making a bigger difference for more patients than they could via direct clinical care. We need talented people in both roles, but we also need to always be looking for ways to minimize the numbers of doctors who feel the need to flee a clinical career.
Like many hospitalists, I think about these things a lot when making decisions about my own career. I hope we all have the wisdom to make the best choices for ourselves, and for the patients we set out to serve when we entered medical school. TH
Hospitalists Can Lend Expertise, Join SHM's Campaign to Improve Antibiotic Stewardship
Many antimicrobial stewards, such as infection prevention specialists, hospital epidemiologists, pharmacists, nurses, and hospitalists, are at the center of quality improvement and seek to achieve optimal clinical outcomes related to antimicrobial use.4 These antimicrobial stewards often strive to minimize harms and other adverse events, reduce the costs of healthcare for infections, and decrease the threat of antimicrobial resistance.3
Hospitalists play a critical role in quality improvement and directly influence inpatient outcomes daily. It’s essential that hospitalists continue to make patient safety and quality care a priority while employing a multidisciplinary approach in implementing antimicrobial stewardship best practices. Although antimicrobial stewardship programs have typically been led by infectious disease physicians and pharmacists, SHM recognizes the significant value of hospitalist leadership and/or participation.5 Although most hospitalists are familiar with the adverse effects of overprescribing antibiotics, their insight and collaboration with other hospital clinicians is necessary in order to Fight the Resistance.
Fight the Resistance, a new behavior change campaign from SHM and our Center for Hospital Innovation and Improvement, is intended to encourage appropriate prescribing and use of antibiotics in the hospital. The campaign’s primary objective is to change prescribing behaviors among hospitalists and other hospital clinicians and facilitate behavior change related to antibiotic prescribing.
The campaign officially launched on Nov. 10, 2015, with a kickoff webinar presented by Scott Flanders, MD, FACP, MHM, and Melhim Bou Alwan, MD. Dr. Flanders discussed the importance of hospitalist involvement in antimicrobial stewardship and the significance of working in multidisciplinary teams in order to reduce overprescribing and the threat of antibiotic resistance.
Dr. Bou Alwan explained SHM’s efforts to fight antimicrobial resistance and informed the audience of SHM’s commitment to antibiotic stewardship. The webinar launch was a huge success, and SHM is excited to continue fighting the resistance with physicians across the country.
In order to Fight the Resistance, SHM is asking hospitalists to commit to the following actions:
- Work with your team. Physicians, nurse practitioners, physician assistants, pharmacists, and infectious disease experts need to work together to ensure that antibiotics are used appropriately. Consider the patients part of your team, too, by discussing with them why antibiotics may not be the best choice of treatment.
- Pay attention to appropriate antibiotic choice and resistance patterns, and identify mechanisms that can be used to educate providers about overprescribing in your hospital.
- Rethink your antibiotic treatment time course. Be sure to adhere to your hospital’s antibiotic treatment guidelines, track use of antibiotics, and set a stop date from when you first prescribe them.
SHM believes changing antibiotic prescription behaviors is a team effort and encourages hospitalists to get involved by visiting www.fighttheresistance.org. There you can find Fight the Resistance themed posters, resources, and educational materials to encourage enhanced stewardship and teamwork in your hospital. TH
Mobola Owolabi is senior project manager for The Center for Hospital Innovation and Improvement
References
- The White House. Office of the Press Secretary. FACT SHEET: Obama Administration releases national action plan to combat antibiotic-resistant bacteria. March 27, 2015. Available at: https://www.whitehouse.gov/the-press-office/2015/03/27/fact-sheet-obama-administration-releases-national-action-plan-combat-ant. Accessed December 3, 2015.
- CDC. Federal engagement in antimicrobial resistance. June 2015. Available at: http://www.cdc.gov/drugresistance/federal-engagement-in-ar/index.html. Accessed December 3, 2015.
- Infectious Diseases Society of America. Promoting antimicrobial stewardship in human medicine. 2015. Available at: http://www.idsociety.org/Stewardship_Policy/. Accessed December 3, 2015.
- CDC. Core elements of hospital antibiotic stewardship programs. 2015. Available at: http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html. Accessed December 3, 2015.
- Rohde JM, Jacobsen D, Rosenberg DJ. Role of the hospitalist in antimicrobial stewardship: a review of work completed and description of a multisite collaborative. Clin Ther. 2013; 35(6):751-757.
Many antimicrobial stewards, such as infection prevention specialists, hospital epidemiologists, pharmacists, nurses, and hospitalists, are at the center of quality improvement and seek to achieve optimal clinical outcomes related to antimicrobial use.4 These antimicrobial stewards often strive to minimize harms and other adverse events, reduce the costs of healthcare for infections, and decrease the threat of antimicrobial resistance.3
Hospitalists play a critical role in quality improvement and directly influence inpatient outcomes daily. It’s essential that hospitalists continue to make patient safety and quality care a priority while employing a multidisciplinary approach in implementing antimicrobial stewardship best practices. Although antimicrobial stewardship programs have typically been led by infectious disease physicians and pharmacists, SHM recognizes the significant value of hospitalist leadership and/or participation.5 Although most hospitalists are familiar with the adverse effects of overprescribing antibiotics, their insight and collaboration with other hospital clinicians is necessary in order to Fight the Resistance.
Fight the Resistance, a new behavior change campaign from SHM and our Center for Hospital Innovation and Improvement, is intended to encourage appropriate prescribing and use of antibiotics in the hospital. The campaign’s primary objective is to change prescribing behaviors among hospitalists and other hospital clinicians and facilitate behavior change related to antibiotic prescribing.
The campaign officially launched on Nov. 10, 2015, with a kickoff webinar presented by Scott Flanders, MD, FACP, MHM, and Melhim Bou Alwan, MD. Dr. Flanders discussed the importance of hospitalist involvement in antimicrobial stewardship and the significance of working in multidisciplinary teams in order to reduce overprescribing and the threat of antibiotic resistance.
Dr. Bou Alwan explained SHM’s efforts to fight antimicrobial resistance and informed the audience of SHM’s commitment to antibiotic stewardship. The webinar launch was a huge success, and SHM is excited to continue fighting the resistance with physicians across the country.
In order to Fight the Resistance, SHM is asking hospitalists to commit to the following actions:
- Work with your team. Physicians, nurse practitioners, physician assistants, pharmacists, and infectious disease experts need to work together to ensure that antibiotics are used appropriately. Consider the patients part of your team, too, by discussing with them why antibiotics may not be the best choice of treatment.
- Pay attention to appropriate antibiotic choice and resistance patterns, and identify mechanisms that can be used to educate providers about overprescribing in your hospital.
- Rethink your antibiotic treatment time course. Be sure to adhere to your hospital’s antibiotic treatment guidelines, track use of antibiotics, and set a stop date from when you first prescribe them.
SHM believes changing antibiotic prescription behaviors is a team effort and encourages hospitalists to get involved by visiting www.fighttheresistance.org. There you can find Fight the Resistance themed posters, resources, and educational materials to encourage enhanced stewardship and teamwork in your hospital. TH
Mobola Owolabi is senior project manager for The Center for Hospital Innovation and Improvement
References
- The White House. Office of the Press Secretary. FACT SHEET: Obama Administration releases national action plan to combat antibiotic-resistant bacteria. March 27, 2015. Available at: https://www.whitehouse.gov/the-press-office/2015/03/27/fact-sheet-obama-administration-releases-national-action-plan-combat-ant. Accessed December 3, 2015.
- CDC. Federal engagement in antimicrobial resistance. June 2015. Available at: http://www.cdc.gov/drugresistance/federal-engagement-in-ar/index.html. Accessed December 3, 2015.
- Infectious Diseases Society of America. Promoting antimicrobial stewardship in human medicine. 2015. Available at: http://www.idsociety.org/Stewardship_Policy/. Accessed December 3, 2015.
- CDC. Core elements of hospital antibiotic stewardship programs. 2015. Available at: http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html. Accessed December 3, 2015.
- Rohde JM, Jacobsen D, Rosenberg DJ. Role of the hospitalist in antimicrobial stewardship: a review of work completed and description of a multisite collaborative. Clin Ther. 2013; 35(6):751-757.
Many antimicrobial stewards, such as infection prevention specialists, hospital epidemiologists, pharmacists, nurses, and hospitalists, are at the center of quality improvement and seek to achieve optimal clinical outcomes related to antimicrobial use.4 These antimicrobial stewards often strive to minimize harms and other adverse events, reduce the costs of healthcare for infections, and decrease the threat of antimicrobial resistance.3
Hospitalists play a critical role in quality improvement and directly influence inpatient outcomes daily. It’s essential that hospitalists continue to make patient safety and quality care a priority while employing a multidisciplinary approach in implementing antimicrobial stewardship best practices. Although antimicrobial stewardship programs have typically been led by infectious disease physicians and pharmacists, SHM recognizes the significant value of hospitalist leadership and/or participation.5 Although most hospitalists are familiar with the adverse effects of overprescribing antibiotics, their insight and collaboration with other hospital clinicians is necessary in order to Fight the Resistance.
Fight the Resistance, a new behavior change campaign from SHM and our Center for Hospital Innovation and Improvement, is intended to encourage appropriate prescribing and use of antibiotics in the hospital. The campaign’s primary objective is to change prescribing behaviors among hospitalists and other hospital clinicians and facilitate behavior change related to antibiotic prescribing.
The campaign officially launched on Nov. 10, 2015, with a kickoff webinar presented by Scott Flanders, MD, FACP, MHM, and Melhim Bou Alwan, MD. Dr. Flanders discussed the importance of hospitalist involvement in antimicrobial stewardship and the significance of working in multidisciplinary teams in order to reduce overprescribing and the threat of antibiotic resistance.
Dr. Bou Alwan explained SHM’s efforts to fight antimicrobial resistance and informed the audience of SHM’s commitment to antibiotic stewardship. The webinar launch was a huge success, and SHM is excited to continue fighting the resistance with physicians across the country.
In order to Fight the Resistance, SHM is asking hospitalists to commit to the following actions:
- Work with your team. Physicians, nurse practitioners, physician assistants, pharmacists, and infectious disease experts need to work together to ensure that antibiotics are used appropriately. Consider the patients part of your team, too, by discussing with them why antibiotics may not be the best choice of treatment.
- Pay attention to appropriate antibiotic choice and resistance patterns, and identify mechanisms that can be used to educate providers about overprescribing in your hospital.
- Rethink your antibiotic treatment time course. Be sure to adhere to your hospital’s antibiotic treatment guidelines, track use of antibiotics, and set a stop date from when you first prescribe them.
SHM believes changing antibiotic prescription behaviors is a team effort and encourages hospitalists to get involved by visiting www.fighttheresistance.org. There you can find Fight the Resistance themed posters, resources, and educational materials to encourage enhanced stewardship and teamwork in your hospital. TH
Mobola Owolabi is senior project manager for The Center for Hospital Innovation and Improvement
References
- The White House. Office of the Press Secretary. FACT SHEET: Obama Administration releases national action plan to combat antibiotic-resistant bacteria. March 27, 2015. Available at: https://www.whitehouse.gov/the-press-office/2015/03/27/fact-sheet-obama-administration-releases-national-action-plan-combat-ant. Accessed December 3, 2015.
- CDC. Federal engagement in antimicrobial resistance. June 2015. Available at: http://www.cdc.gov/drugresistance/federal-engagement-in-ar/index.html. Accessed December 3, 2015.
- Infectious Diseases Society of America. Promoting antimicrobial stewardship in human medicine. 2015. Available at: http://www.idsociety.org/Stewardship_Policy/. Accessed December 3, 2015.
- CDC. Core elements of hospital antibiotic stewardship programs. 2015. Available at: http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html. Accessed December 3, 2015.
- Rohde JM, Jacobsen D, Rosenberg DJ. Role of the hospitalist in antimicrobial stewardship: a review of work completed and description of a multisite collaborative. Clin Ther. 2013; 35(6):751-757.
Effectiveness of Antipsychotics in Treatment of Delirium
Clinical questions: Are antipsychotics for the treatment of delirium safe and effective? Does efficacy differ between ICU and non-ICU settings? Does efficacy differ between first- and second-generation antipsychotics (SGA)?
Background: Delirium is common in hospitalized patients. Data are mixed about the use of antipsychotics for treatment of delirium, and safety concerns are well founded. A 2007 Cochrane review failed to show compelling evidence for their efficacy, yet they remain widely used for this purpose.
Study design: Systematic review and meta-analysis.
Setting: Fifteen RCTs of adults with delirium.
Synopsis: The primary outcome measure was response rate at the study endpoint, defined using severity of delirium and global scales.
In a comparison of pooled or individual antipsychotics vs. placebo or usual care (UC), antipsychotics were found to be superior, with a response rate of 0.22 (95% CI, 0.15-0.34, P<.00001), NNT=2. Subgroup analysis revealed this superiority to be greater in non-ICU settings, with ICU antipsychotic use only marginally better than UC. Antipsychotics were superior in time to response (TTR). Mortality rates were no different.
There were no differences between chlorpromazine and haloperidol in any outcomes. Among head-to-head comparisons of SGAs, no differences were found. Pooled or individual SGAs, however, had the same overall efficacy as haloperidol but shorter TTR and fewer extrapyramidal side effects. Subgroup analysis showed a small but significant advantage in the use of SGAs over haloperidol in the ICU.
Bottom line: Antipsychotics are more effective than placebo or usual care in the treatment of delirium. There appears to be a benefit to using second-generation antipsychotics over haloperidol.
Citation: Kishi T, Hirota T, Matsunaga S, Iwata N. Antipsychotic medications for the treatment of delirium: a systematic review and meta-analysis of randomised controlled trials. J Neurol Neurosurg Psychiatry. 2015;0:1-8.
Clinical questions: Are antipsychotics for the treatment of delirium safe and effective? Does efficacy differ between ICU and non-ICU settings? Does efficacy differ between first- and second-generation antipsychotics (SGA)?
Background: Delirium is common in hospitalized patients. Data are mixed about the use of antipsychotics for treatment of delirium, and safety concerns are well founded. A 2007 Cochrane review failed to show compelling evidence for their efficacy, yet they remain widely used for this purpose.
Study design: Systematic review and meta-analysis.
Setting: Fifteen RCTs of adults with delirium.
Synopsis: The primary outcome measure was response rate at the study endpoint, defined using severity of delirium and global scales.
In a comparison of pooled or individual antipsychotics vs. placebo or usual care (UC), antipsychotics were found to be superior, with a response rate of 0.22 (95% CI, 0.15-0.34, P<.00001), NNT=2. Subgroup analysis revealed this superiority to be greater in non-ICU settings, with ICU antipsychotic use only marginally better than UC. Antipsychotics were superior in time to response (TTR). Mortality rates were no different.
There were no differences between chlorpromazine and haloperidol in any outcomes. Among head-to-head comparisons of SGAs, no differences were found. Pooled or individual SGAs, however, had the same overall efficacy as haloperidol but shorter TTR and fewer extrapyramidal side effects. Subgroup analysis showed a small but significant advantage in the use of SGAs over haloperidol in the ICU.
Bottom line: Antipsychotics are more effective than placebo or usual care in the treatment of delirium. There appears to be a benefit to using second-generation antipsychotics over haloperidol.
Citation: Kishi T, Hirota T, Matsunaga S, Iwata N. Antipsychotic medications for the treatment of delirium: a systematic review and meta-analysis of randomised controlled trials. J Neurol Neurosurg Psychiatry. 2015;0:1-8.
Clinical questions: Are antipsychotics for the treatment of delirium safe and effective? Does efficacy differ between ICU and non-ICU settings? Does efficacy differ between first- and second-generation antipsychotics (SGA)?
Background: Delirium is common in hospitalized patients. Data are mixed about the use of antipsychotics for treatment of delirium, and safety concerns are well founded. A 2007 Cochrane review failed to show compelling evidence for their efficacy, yet they remain widely used for this purpose.
Study design: Systematic review and meta-analysis.
Setting: Fifteen RCTs of adults with delirium.
Synopsis: The primary outcome measure was response rate at the study endpoint, defined using severity of delirium and global scales.
In a comparison of pooled or individual antipsychotics vs. placebo or usual care (UC), antipsychotics were found to be superior, with a response rate of 0.22 (95% CI, 0.15-0.34, P<.00001), NNT=2. Subgroup analysis revealed this superiority to be greater in non-ICU settings, with ICU antipsychotic use only marginally better than UC. Antipsychotics were superior in time to response (TTR). Mortality rates were no different.
There were no differences between chlorpromazine and haloperidol in any outcomes. Among head-to-head comparisons of SGAs, no differences were found. Pooled or individual SGAs, however, had the same overall efficacy as haloperidol but shorter TTR and fewer extrapyramidal side effects. Subgroup analysis showed a small but significant advantage in the use of SGAs over haloperidol in the ICU.
Bottom line: Antipsychotics are more effective than placebo or usual care in the treatment of delirium. There appears to be a benefit to using second-generation antipsychotics over haloperidol.
Citation: Kishi T, Hirota T, Matsunaga S, Iwata N. Antipsychotic medications for the treatment of delirium: a systematic review and meta-analysis of randomised controlled trials. J Neurol Neurosurg Psychiatry. 2015;0:1-8.
Predictors for Surgical Management of Small Bowel Obstruction
Clinical question: Are there clinical or computerized tomography (CT) findings that identify which patients will need early surgical management in adhesive small bowel obstruction (ASBO)?
Background: Previous studies determined adverse outcomes resulting from delayed surgery in patients with ASBO: increased length of stay (LOS), complications, and mortality. Most patients respond to nonoperative management, however.
Study design: Prospective observational study.
Setting: Three academic and tertiary referral medical centers.
Synopsis: Using multivariate analysis of 202 patients admitted with presumed adhesive ASBO without immediate surgical need, of whom 52 required eventual surgical intervention, this study found three predictors for needing operative care: no flatus (odds ratio [OR], 3.28; 95% confidence interval [CI], 1.51-7.12; P=0.003), as well as the CT findings of a high-grade obstruction, defined as only minimal passage of air and fluid into the distal small bowel or colon (OR, 2.44; 95% CI, 1.10-5.43; P=0.028) or the presence of free fluid (OR, 2.59; 95% CI, 1.13-5.90; P=0.023).
Despite these associations, clinicians should not view these findings as indications for surgery. Of the patients who responded to nonoperative management, one-third had no flatus, and on CT one-third had high-grade obstruction and half had free fluid. Instead, because patients with these findings are at an increased risk of failing nonoperative management, they should be observed more closely and reassessed more frequently.
Bottom line: Patients without flatus or with the presence of free fluid or high-grade obstruction on CT are at an increased risk of requiring surgical management for ASBO.
Citation: Kulvatunyou N, Pandit V, Moutamn S, et al. A multi-institution prospective observational study of small bowel obstruction: clinical and computerized tomography predictors of which patients may require early surgery. J Trauma Acute Care Surg. 2015;79(3):393-398.
Clinical question: Are there clinical or computerized tomography (CT) findings that identify which patients will need early surgical management in adhesive small bowel obstruction (ASBO)?
Background: Previous studies determined adverse outcomes resulting from delayed surgery in patients with ASBO: increased length of stay (LOS), complications, and mortality. Most patients respond to nonoperative management, however.
Study design: Prospective observational study.
Setting: Three academic and tertiary referral medical centers.
Synopsis: Using multivariate analysis of 202 patients admitted with presumed adhesive ASBO without immediate surgical need, of whom 52 required eventual surgical intervention, this study found three predictors for needing operative care: no flatus (odds ratio [OR], 3.28; 95% confidence interval [CI], 1.51-7.12; P=0.003), as well as the CT findings of a high-grade obstruction, defined as only minimal passage of air and fluid into the distal small bowel or colon (OR, 2.44; 95% CI, 1.10-5.43; P=0.028) or the presence of free fluid (OR, 2.59; 95% CI, 1.13-5.90; P=0.023).
Despite these associations, clinicians should not view these findings as indications for surgery. Of the patients who responded to nonoperative management, one-third had no flatus, and on CT one-third had high-grade obstruction and half had free fluid. Instead, because patients with these findings are at an increased risk of failing nonoperative management, they should be observed more closely and reassessed more frequently.
Bottom line: Patients without flatus or with the presence of free fluid or high-grade obstruction on CT are at an increased risk of requiring surgical management for ASBO.
Citation: Kulvatunyou N, Pandit V, Moutamn S, et al. A multi-institution prospective observational study of small bowel obstruction: clinical and computerized tomography predictors of which patients may require early surgery. J Trauma Acute Care Surg. 2015;79(3):393-398.
Clinical question: Are there clinical or computerized tomography (CT) findings that identify which patients will need early surgical management in adhesive small bowel obstruction (ASBO)?
Background: Previous studies determined adverse outcomes resulting from delayed surgery in patients with ASBO: increased length of stay (LOS), complications, and mortality. Most patients respond to nonoperative management, however.
Study design: Prospective observational study.
Setting: Three academic and tertiary referral medical centers.
Synopsis: Using multivariate analysis of 202 patients admitted with presumed adhesive ASBO without immediate surgical need, of whom 52 required eventual surgical intervention, this study found three predictors for needing operative care: no flatus (odds ratio [OR], 3.28; 95% confidence interval [CI], 1.51-7.12; P=0.003), as well as the CT findings of a high-grade obstruction, defined as only minimal passage of air and fluid into the distal small bowel or colon (OR, 2.44; 95% CI, 1.10-5.43; P=0.028) or the presence of free fluid (OR, 2.59; 95% CI, 1.13-5.90; P=0.023).
Despite these associations, clinicians should not view these findings as indications for surgery. Of the patients who responded to nonoperative management, one-third had no flatus, and on CT one-third had high-grade obstruction and half had free fluid. Instead, because patients with these findings are at an increased risk of failing nonoperative management, they should be observed more closely and reassessed more frequently.
Bottom line: Patients without flatus or with the presence of free fluid or high-grade obstruction on CT are at an increased risk of requiring surgical management for ASBO.
Citation: Kulvatunyou N, Pandit V, Moutamn S, et al. A multi-institution prospective observational study of small bowel obstruction: clinical and computerized tomography predictors of which patients may require early surgery. J Trauma Acute Care Surg. 2015;79(3):393-398.
Adding Advanced Molecular Techniques to Standard Blood Cultures May Improve Patient Outcomes
Clinical question: Does the addition of rapid multiplex polymerase chain reaction molecular techniques to standard blood culture bottle (BCB) processing, with or without antimicrobial stewardship recommendations, affect antimicrobial utilization and patient outcomes?
Background: Standard BCB processing typically requires two days to provide identification and susceptibility testing results. PCR-based molecular testing is available to test positive BCB and deliver specific susceptibility results more rapidly, typically within one hour. Earlier results could improve antimicrobial utilization, limit antimicrobial resistance, decrease the risk of Clostridium difficile colitis, improve patient outcomes, and decrease healthcare costs. The impact of these techniques on outcomes is uncertain.
Study design: Prospective, randomized controlled trial (RCT).
Setting: Single large tertiary academic medical center.
Synopsis: Nearly 750 patients were randomized to conventional BCB processing (control), BCB with rapid multiplex PCR and templated recommendations (rmPCR), or BCB with rapid multiplex PCR and real-time antimicrobial stewardship provided by an infectious disease physician or specially trained pharmacist (rmPCR/AS). Time to microorganism identification was reduced from 22.3 hours in the control arm to 1.3 hours in the intervention arms. Both intervention groups had decreased use of broad spectrum piperacillin-tazobactam, increased use of narrow spectrum β-lactam, and decreased treatment of contaminants. Time to appropriate empiric treatment modification was shortest in the rmPCR/AS group.
Groups did not differ in mortality, length of stay, or cost, although an adequately powered study may show beneficial effects in these outcomes.
Bottom line: The addition of rapid multiplex PCR, ideally combined with antimicrobial stewardship, improves antimicrobial utilization in patients with positive blood cultures.
Citation: Banerjee R, Teng CB, Cunningham SA, et al. Randomized trial of rapid multiplex polymerase chain reaction-based blood culture identification and susceptibility testing. Clin Infect Dis. 2015;61(7):1071-1080.
Clinical question: Does the addition of rapid multiplex polymerase chain reaction molecular techniques to standard blood culture bottle (BCB) processing, with or without antimicrobial stewardship recommendations, affect antimicrobial utilization and patient outcomes?
Background: Standard BCB processing typically requires two days to provide identification and susceptibility testing results. PCR-based molecular testing is available to test positive BCB and deliver specific susceptibility results more rapidly, typically within one hour. Earlier results could improve antimicrobial utilization, limit antimicrobial resistance, decrease the risk of Clostridium difficile colitis, improve patient outcomes, and decrease healthcare costs. The impact of these techniques on outcomes is uncertain.
Study design: Prospective, randomized controlled trial (RCT).
Setting: Single large tertiary academic medical center.
Synopsis: Nearly 750 patients were randomized to conventional BCB processing (control), BCB with rapid multiplex PCR and templated recommendations (rmPCR), or BCB with rapid multiplex PCR and real-time antimicrobial stewardship provided by an infectious disease physician or specially trained pharmacist (rmPCR/AS). Time to microorganism identification was reduced from 22.3 hours in the control arm to 1.3 hours in the intervention arms. Both intervention groups had decreased use of broad spectrum piperacillin-tazobactam, increased use of narrow spectrum β-lactam, and decreased treatment of contaminants. Time to appropriate empiric treatment modification was shortest in the rmPCR/AS group.
Groups did not differ in mortality, length of stay, or cost, although an adequately powered study may show beneficial effects in these outcomes.
Bottom line: The addition of rapid multiplex PCR, ideally combined with antimicrobial stewardship, improves antimicrobial utilization in patients with positive blood cultures.
Citation: Banerjee R, Teng CB, Cunningham SA, et al. Randomized trial of rapid multiplex polymerase chain reaction-based blood culture identification and susceptibility testing. Clin Infect Dis. 2015;61(7):1071-1080.
Clinical question: Does the addition of rapid multiplex polymerase chain reaction molecular techniques to standard blood culture bottle (BCB) processing, with or without antimicrobial stewardship recommendations, affect antimicrobial utilization and patient outcomes?
Background: Standard BCB processing typically requires two days to provide identification and susceptibility testing results. PCR-based molecular testing is available to test positive BCB and deliver specific susceptibility results more rapidly, typically within one hour. Earlier results could improve antimicrobial utilization, limit antimicrobial resistance, decrease the risk of Clostridium difficile colitis, improve patient outcomes, and decrease healthcare costs. The impact of these techniques on outcomes is uncertain.
Study design: Prospective, randomized controlled trial (RCT).
Setting: Single large tertiary academic medical center.
Synopsis: Nearly 750 patients were randomized to conventional BCB processing (control), BCB with rapid multiplex PCR and templated recommendations (rmPCR), or BCB with rapid multiplex PCR and real-time antimicrobial stewardship provided by an infectious disease physician or specially trained pharmacist (rmPCR/AS). Time to microorganism identification was reduced from 22.3 hours in the control arm to 1.3 hours in the intervention arms. Both intervention groups had decreased use of broad spectrum piperacillin-tazobactam, increased use of narrow spectrum β-lactam, and decreased treatment of contaminants. Time to appropriate empiric treatment modification was shortest in the rmPCR/AS group.
Groups did not differ in mortality, length of stay, or cost, although an adequately powered study may show beneficial effects in these outcomes.
Bottom line: The addition of rapid multiplex PCR, ideally combined with antimicrobial stewardship, improves antimicrobial utilization in patients with positive blood cultures.
Citation: Banerjee R, Teng CB, Cunningham SA, et al. Randomized trial of rapid multiplex polymerase chain reaction-based blood culture identification and susceptibility testing. Clin Infect Dis. 2015;61(7):1071-1080.
A Look at Speakers, Educational Tracks Planned for Hospital Medicine 2016
Get ready for hospital medicine’s main event—Hospital Medicine 2016 (HM16). SHM remains at the forefront of healthcare, leading the charge to provide the best care for hospitalized patients. We invite you to join us on the sunny shores of San Diego from March 6-9, to learn about the latest advances in hospital medicine and connect with over 3,000 hospital-based professionals.
On hand this year will be some world-class faculty, who will examine today’s issues and challenge everyone to be a part of the solution. HM16’s renowned speakers are leaders in the field. We proudly welcome:
Karen DeSalvo, MD, MPH, MSc
Acting Assistant Secretary for Health, U.S. Department of Health and Human Services
Dr. DeSalvo has made a tremendous impact on quality in healthcare through direct patient care, medical education, policy and administrative roles, research, and public service. She has received many honors, including recognition as a “Woman of Excellence in Health Care” by the Louisiana Legislative Women’s Caucus. Join her for her featured address, “Public Health 3.0, the Role of the Hospitalist and Hospital.”
Robert M. Wachter, MD, MHM
Professor and interim chair, department of medicine, University of California San Francisco, author of “The Digital Doctor: Hope, Hype and Harm at the Dawn of Medicine’s Computer Age,” and of the HM-focused blog, “Wachter’s World."
Dr. Wachter, national thought leader in healthcare quality improvement, in his always entertaining style, will address important and interesting work going on in medical leadership, teamwork, artificial intelligence, and physician evaluation. Join him for his closing keynote address: “Hospital Medicine Turns 20: Celebrating the Past While Charting a New Course.”
In addition to these much anticipated keynotes, be sure to check out new tracks for HM16, including:
• Co-Management/Perioperative Medicine: This hospitalist core competency increases in complexity, yet many physicians were not even taught the basics in residency. This new track explores the perioperative and consultative medicine questions that challenge hospitalists on a daily basis.
• Health IT for Hospitalists: Technology has changed the practice of medicine. The new Health IT for Hospitalists track focuses on topics to help frontline clinicians perform better by using technology, while helping those with leadership roles in Health IT obtain tools to make them more effective. HM2016 will mark the beginning of an annual update on the best mobile apps in the healthcare sector.
• Post-Acute Care: This track targets two audiences: 1) mainstream hospitalists, who increasingly are being asked to assume responsibility for the full episode of care, including post-acute care services after discharge; 2) hospitalists in programs who have assumed responsibility for post-acute care services, either in skilled nursing facilities, independent rehabilitation facilities, or long-term acute care hospitals. This track will provide information on how hospitalists can build and operate a successful post-acute care practice.
These are sessions you won’t want to miss! If you haven’t registered, now is the time. SHM members save $325 on HM16 registration, and if you’re new to SHM, you can receive one free year of membership after registering.
Get the scoop on all things HM16, and register now, at www.hospitalmedicine2016.org.
See you in San Diego! TH
Brett Radler is SHM’s communications coordinator.
Get ready for hospital medicine’s main event—Hospital Medicine 2016 (HM16). SHM remains at the forefront of healthcare, leading the charge to provide the best care for hospitalized patients. We invite you to join us on the sunny shores of San Diego from March 6-9, to learn about the latest advances in hospital medicine and connect with over 3,000 hospital-based professionals.
On hand this year will be some world-class faculty, who will examine today’s issues and challenge everyone to be a part of the solution. HM16’s renowned speakers are leaders in the field. We proudly welcome:
Karen DeSalvo, MD, MPH, MSc
Acting Assistant Secretary for Health, U.S. Department of Health and Human Services
Dr. DeSalvo has made a tremendous impact on quality in healthcare through direct patient care, medical education, policy and administrative roles, research, and public service. She has received many honors, including recognition as a “Woman of Excellence in Health Care” by the Louisiana Legislative Women’s Caucus. Join her for her featured address, “Public Health 3.0, the Role of the Hospitalist and Hospital.”
Robert M. Wachter, MD, MHM
Professor and interim chair, department of medicine, University of California San Francisco, author of “The Digital Doctor: Hope, Hype and Harm at the Dawn of Medicine’s Computer Age,” and of the HM-focused blog, “Wachter’s World."
Dr. Wachter, national thought leader in healthcare quality improvement, in his always entertaining style, will address important and interesting work going on in medical leadership, teamwork, artificial intelligence, and physician evaluation. Join him for his closing keynote address: “Hospital Medicine Turns 20: Celebrating the Past While Charting a New Course.”
In addition to these much anticipated keynotes, be sure to check out new tracks for HM16, including:
• Co-Management/Perioperative Medicine: This hospitalist core competency increases in complexity, yet many physicians were not even taught the basics in residency. This new track explores the perioperative and consultative medicine questions that challenge hospitalists on a daily basis.
• Health IT for Hospitalists: Technology has changed the practice of medicine. The new Health IT for Hospitalists track focuses on topics to help frontline clinicians perform better by using technology, while helping those with leadership roles in Health IT obtain tools to make them more effective. HM2016 will mark the beginning of an annual update on the best mobile apps in the healthcare sector.
• Post-Acute Care: This track targets two audiences: 1) mainstream hospitalists, who increasingly are being asked to assume responsibility for the full episode of care, including post-acute care services after discharge; 2) hospitalists in programs who have assumed responsibility for post-acute care services, either in skilled nursing facilities, independent rehabilitation facilities, or long-term acute care hospitals. This track will provide information on how hospitalists can build and operate a successful post-acute care practice.
These are sessions you won’t want to miss! If you haven’t registered, now is the time. SHM members save $325 on HM16 registration, and if you’re new to SHM, you can receive one free year of membership after registering.
Get the scoop on all things HM16, and register now, at www.hospitalmedicine2016.org.
See you in San Diego! TH
Brett Radler is SHM’s communications coordinator.
Get ready for hospital medicine’s main event—Hospital Medicine 2016 (HM16). SHM remains at the forefront of healthcare, leading the charge to provide the best care for hospitalized patients. We invite you to join us on the sunny shores of San Diego from March 6-9, to learn about the latest advances in hospital medicine and connect with over 3,000 hospital-based professionals.
On hand this year will be some world-class faculty, who will examine today’s issues and challenge everyone to be a part of the solution. HM16’s renowned speakers are leaders in the field. We proudly welcome:
Karen DeSalvo, MD, MPH, MSc
Acting Assistant Secretary for Health, U.S. Department of Health and Human Services
Dr. DeSalvo has made a tremendous impact on quality in healthcare through direct patient care, medical education, policy and administrative roles, research, and public service. She has received many honors, including recognition as a “Woman of Excellence in Health Care” by the Louisiana Legislative Women’s Caucus. Join her for her featured address, “Public Health 3.0, the Role of the Hospitalist and Hospital.”
Robert M. Wachter, MD, MHM
Professor and interim chair, department of medicine, University of California San Francisco, author of “The Digital Doctor: Hope, Hype and Harm at the Dawn of Medicine’s Computer Age,” and of the HM-focused blog, “Wachter’s World."
Dr. Wachter, national thought leader in healthcare quality improvement, in his always entertaining style, will address important and interesting work going on in medical leadership, teamwork, artificial intelligence, and physician evaluation. Join him for his closing keynote address: “Hospital Medicine Turns 20: Celebrating the Past While Charting a New Course.”
In addition to these much anticipated keynotes, be sure to check out new tracks for HM16, including:
• Co-Management/Perioperative Medicine: This hospitalist core competency increases in complexity, yet many physicians were not even taught the basics in residency. This new track explores the perioperative and consultative medicine questions that challenge hospitalists on a daily basis.
• Health IT for Hospitalists: Technology has changed the practice of medicine. The new Health IT for Hospitalists track focuses on topics to help frontline clinicians perform better by using technology, while helping those with leadership roles in Health IT obtain tools to make them more effective. HM2016 will mark the beginning of an annual update on the best mobile apps in the healthcare sector.
• Post-Acute Care: This track targets two audiences: 1) mainstream hospitalists, who increasingly are being asked to assume responsibility for the full episode of care, including post-acute care services after discharge; 2) hospitalists in programs who have assumed responsibility for post-acute care services, either in skilled nursing facilities, independent rehabilitation facilities, or long-term acute care hospitals. This track will provide information on how hospitalists can build and operate a successful post-acute care practice.
These are sessions you won’t want to miss! If you haven’t registered, now is the time. SHM members save $325 on HM16 registration, and if you’re new to SHM, you can receive one free year of membership after registering.
Get the scoop on all things HM16, and register now, at www.hospitalmedicine2016.org.
See you in San Diego! TH
Brett Radler is SHM’s communications coordinator.
