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When a patient must remain in the acute care hospital setting—despite being well enough to transition to a lower level of care, costs continue to mount as the patient receives care at the most expensive level.

“But policymakers must understand that reducing support for essential hospitals might save dollars in the short term but ultimately threatens access to care and creates greater costs in the long run,” says Beth Feldpush, DrPH, senior vice president of policy and advocacy for America’s Essential Hospitals in Washington, D.C. The group represents more than 250 essential hospitals, which fill a safety net role and provide communitywide services, such as trauma, neonatal intensive care, and disaster response.

“Our hospitals, which already operate at a loss on average, cannot continue to sustain federal and state funding cuts,” Dr. Feldpush says. “Access to care for vulnerable patients and entire communities will suffer if we continue to chip away at crucial sources of support, such as Medicaid and Medicare disproportionate share hospital funding and payment for outpatient services.”

The Affordable Care Act (ACA) makes many changes to the healthcare system that are designed to improve the quality, value of, and access to healthcare services.

“While many are good in theory, they have faced challenges in practice,” Dr. Feldpush says.

For example, the law’s authors included deep cuts to Medicaid and Medicare disproportionate share hospital (DSH) payments, which support hospitals that provide a large volume of uncompensated care. They made these cuts with the assumption that Medicare expansion and the ACA health insurance marketplace would significantly increase coverage, lessening the need for DSH payments. The U.S. Supreme Court’s decision to give states the option of expanding Medicaid has resulted in expansion in only about half of the states, however.

“But the DSH cuts remain, meaning our hospitals are getting significantly less support for the same or more uncompensated care,” Dr. Feldpush says.

Likewise, the ACA put into place many quality incentive programs for Medicare, including those designed to reduce preventable readmissions and hospital-acquired conditions and to encourage more value-based purchasing.

“The goals are obviously good ones, but the quality measures used to calculate incentive payments or penalties fail to account for the sociodemographic challenges our patients face—and that our hospitals can’t control,” she says. “So, these programs disproportionately penalize our hospitals, which, in turn, creates a vicious circle that reduces the funding they need to make improvements.”

Access to equitable healthcare for low-income, uninsured, and other vulnerable patients is a national problem, Dr. Feldpush continues. But the severity of the problem can vary by community and region—in states that have chosen not to expand their Medicaid programs, for example, or in economically depressed areas. TH

When a patient must remain in the acute care hospital setting—despite being well enough to transition to a lower level of care, costs continue to mount as the patient receives care at the most expensive level.

“But policymakers must understand that reducing support for essential hospitals might save dollars in the short term but ultimately threatens access to care and creates greater costs in the long run,” says Beth Feldpush, DrPH, senior vice president of policy and advocacy for America’s Essential Hospitals in Washington, D.C. The group represents more than 250 essential hospitals, which fill a safety net role and provide communitywide services, such as trauma, neonatal intensive care, and disaster response.

“Our hospitals, which already operate at a loss on average, cannot continue to sustain federal and state funding cuts,” Dr. Feldpush says. “Access to care for vulnerable patients and entire communities will suffer if we continue to chip away at crucial sources of support, such as Medicaid and Medicare disproportionate share hospital funding and payment for outpatient services.”

The Affordable Care Act (ACA) makes many changes to the healthcare system that are designed to improve the quality, value of, and access to healthcare services.

“While many are good in theory, they have faced challenges in practice,” Dr. Feldpush says.

For example, the law’s authors included deep cuts to Medicaid and Medicare disproportionate share hospital (DSH) payments, which support hospitals that provide a large volume of uncompensated care. They made these cuts with the assumption that Medicare expansion and the ACA health insurance marketplace would significantly increase coverage, lessening the need for DSH payments. The U.S. Supreme Court’s decision to give states the option of expanding Medicaid has resulted in expansion in only about half of the states, however.

“But the DSH cuts remain, meaning our hospitals are getting significantly less support for the same or more uncompensated care,” Dr. Feldpush says.

Likewise, the ACA put into place many quality incentive programs for Medicare, including those designed to reduce preventable readmissions and hospital-acquired conditions and to encourage more value-based purchasing.

“The goals are obviously good ones, but the quality measures used to calculate incentive payments or penalties fail to account for the sociodemographic challenges our patients face—and that our hospitals can’t control,” she says. “So, these programs disproportionately penalize our hospitals, which, in turn, creates a vicious circle that reduces the funding they need to make improvements.”

Access to equitable healthcare for low-income, uninsured, and other vulnerable patients is a national problem, Dr. Feldpush continues. But the severity of the problem can vary by community and region—in states that have chosen not to expand their Medicaid programs, for example, or in economically depressed areas. TH

When a patient must remain in the acute care hospital setting—despite being well enough to transition to a lower level of care, costs continue to mount as the patient receives care at the most expensive level.

“But policymakers must understand that reducing support for essential hospitals might save dollars in the short term but ultimately threatens access to care and creates greater costs in the long run,” says Beth Feldpush, DrPH, senior vice president of policy and advocacy for America’s Essential Hospitals in Washington, D.C. The group represents more than 250 essential hospitals, which fill a safety net role and provide communitywide services, such as trauma, neonatal intensive care, and disaster response.

“Our hospitals, which already operate at a loss on average, cannot continue to sustain federal and state funding cuts,” Dr. Feldpush says. “Access to care for vulnerable patients and entire communities will suffer if we continue to chip away at crucial sources of support, such as Medicaid and Medicare disproportionate share hospital funding and payment for outpatient services.”

The Affordable Care Act (ACA) makes many changes to the healthcare system that are designed to improve the quality, value of, and access to healthcare services.

“While many are good in theory, they have faced challenges in practice,” Dr. Feldpush says.

For example, the law’s authors included deep cuts to Medicaid and Medicare disproportionate share hospital (DSH) payments, which support hospitals that provide a large volume of uncompensated care. They made these cuts with the assumption that Medicare expansion and the ACA health insurance marketplace would significantly increase coverage, lessening the need for DSH payments. The U.S. Supreme Court’s decision to give states the option of expanding Medicaid has resulted in expansion in only about half of the states, however.

“But the DSH cuts remain, meaning our hospitals are getting significantly less support for the same or more uncompensated care,” Dr. Feldpush says.

Likewise, the ACA put into place many quality incentive programs for Medicare, including those designed to reduce preventable readmissions and hospital-acquired conditions and to encourage more value-based purchasing.

“The goals are obviously good ones, but the quality measures used to calculate incentive payments or penalties fail to account for the sociodemographic challenges our patients face—and that our hospitals can’t control,” she says. “So, these programs disproportionately penalize our hospitals, which, in turn, creates a vicious circle that reduces the funding they need to make improvements.”

Access to equitable healthcare for low-income, uninsured, and other vulnerable patients is a national problem, Dr. Feldpush continues. But the severity of the problem can vary by community and region—in states that have chosen not to expand their Medicaid programs, for example, or in economically depressed areas. TH

Nearly all medical-device monitoring alerts on regular hospital units were found not to be actionable, according to a study by pediatrician and researcher Chris Bonafide, MD, MSCE, at Children’s Hospital of Philadelphia, based on reviewing hours of video from patient rooms.¹

Reference

1. Bonafide CP, Lin R, Zander M, et al. Association between exposure to nonactionable physiologic monitor alarms and response time in a children’s hospital. J Hosp Med. 2015; 10(6):345–351.

Nearly all medical-device monitoring alerts on regular hospital units were found not to be actionable, according to a study by pediatrician and researcher Chris Bonafide, MD, MSCE, at Children’s Hospital of Philadelphia, based on reviewing hours of video from patient rooms.¹

Reference

1. Bonafide CP, Lin R, Zander M, et al. Association between exposure to nonactionable physiologic monitor alarms and response time in a children’s hospital. J Hosp Med. 2015; 10(6):345–351.

Nearly all medical-device monitoring alerts on regular hospital units were found not to be actionable, according to a study by pediatrician and researcher Chris Bonafide, MD, MSCE, at Children’s Hospital of Philadelphia, based on reviewing hours of video from patient rooms.¹

Reference

1. Bonafide CP, Lin R, Zander M, et al. Association between exposure to nonactionable physiologic monitor alarms and response time in a children’s hospital. J Hosp Med. 2015; 10(6):345–351.

Clinical question: In patients with atrial fibrillation (AF) or flutter, is heparin bridging needed during interruption of warfarin therapy for surgery or invasive procedures?

Background: Bridging is intended to decrease the risk of stroke or other arterial thromboembolism by minimizing time off anticoagulation. Bridging may increase the risk of serious bleeding, offsetting any benefit. Guidelines have provided weak and inconsistent recommendations due to a lack of randomized trials.

Study design: Randomized, double blind, placebo-controlled trial.

Setting: More than 100 centers in the U.S. and Canada, from 2009-2014.

Synopsis: Investigators randomized 1,884 patients on warfarin with a CHADS² risk factor of one or higher undergoing elective surgery or procedure to dalteparin or placebo, from three days to 24 hours before the procedure and for five to 10 days after. Mean CHADS² score was 2.3; 3% of patients had scores of five to six. Approximately one-third of patients were on aspirin, and most procedures (89%) were classified as minor. Patients with mechanical heart valves, stroke/transient ischemic attack (TIA)/systemic embolization within 12 weeks, major bleeding within six weeks, renal insufficiency, thrombocytopenia or planned cardiac, intracranial, or intraspinal surgery were excluded.

Thirty-day incidence of arterial thromboembolism (stroke, TIA, systemic embolization) was 0.4% in the non-bridging group and 0.3% in the bridging group (P=0.01 for noninferiority). Patients suffering arterial thromboembolism had mean CHADS² scores of 2.6; most events occurred after minor procedures. Major bleeding was less common with no bridge (1.3% vs. 3.2%, relative risk 0.41, P=0.005 for superiority).

In this trial, most patients underwent minor procedures and few CHADS² 5-6 patients were enrolled; however, this well-designed, randomized trial adds important evidence to existing observational data.

Bottom line: Bridging is not warranted for most AF patients with CHADS2 scores of four or lower, at least for low-risk procedures.

Citation: Douketis JD, Spyropoulos AC, Kaatz S, et al. Perioperative bridging anticoagulation in patients with atrial fibrillation. N Engl J Med. 2015;373(9):823-833.

Clinical question: In patients with atrial fibrillation (AF) or flutter, is heparin bridging needed during interruption of warfarin therapy for surgery or invasive procedures?

Background: Bridging is intended to decrease the risk of stroke or other arterial thromboembolism by minimizing time off anticoagulation. Bridging may increase the risk of serious bleeding, offsetting any benefit. Guidelines have provided weak and inconsistent recommendations due to a lack of randomized trials.

Study design: Randomized, double blind, placebo-controlled trial.

Setting: More than 100 centers in the U.S. and Canada, from 2009-2014.

Synopsis: Investigators randomized 1,884 patients on warfarin with a CHADS² risk factor of one or higher undergoing elective surgery or procedure to dalteparin or placebo, from three days to 24 hours before the procedure and for five to 10 days after. Mean CHADS² score was 2.3; 3% of patients had scores of five to six. Approximately one-third of patients were on aspirin, and most procedures (89%) were classified as minor. Patients with mechanical heart valves, stroke/transient ischemic attack (TIA)/systemic embolization within 12 weeks, major bleeding within six weeks, renal insufficiency, thrombocytopenia or planned cardiac, intracranial, or intraspinal surgery were excluded.

Thirty-day incidence of arterial thromboembolism (stroke, TIA, systemic embolization) was 0.4% in the non-bridging group and 0.3% in the bridging group (P=0.01 for noninferiority). Patients suffering arterial thromboembolism had mean CHADS² scores of 2.6; most events occurred after minor procedures. Major bleeding was less common with no bridge (1.3% vs. 3.2%, relative risk 0.41, P=0.005 for superiority).

In this trial, most patients underwent minor procedures and few CHADS² 5-6 patients were enrolled; however, this well-designed, randomized trial adds important evidence to existing observational data.

Bottom line: Bridging is not warranted for most AF patients with CHADS2 scores of four or lower, at least for low-risk procedures.

Citation: Douketis JD, Spyropoulos AC, Kaatz S, et al. Perioperative bridging anticoagulation in patients with atrial fibrillation. N Engl J Med. 2015;373(9):823-833.

Clinical question: In patients with atrial fibrillation (AF) or flutter, is heparin bridging needed during interruption of warfarin therapy for surgery or invasive procedures?

Background: Bridging is intended to decrease the risk of stroke or other arterial thromboembolism by minimizing time off anticoagulation. Bridging may increase the risk of serious bleeding, offsetting any benefit. Guidelines have provided weak and inconsistent recommendations due to a lack of randomized trials.

Study design: Randomized, double blind, placebo-controlled trial.

Setting: More than 100 centers in the U.S. and Canada, from 2009-2014.

Synopsis: Investigators randomized 1,884 patients on warfarin with a CHADS² risk factor of one or higher undergoing elective surgery or procedure to dalteparin or placebo, from three days to 24 hours before the procedure and for five to 10 days after. Mean CHADS² score was 2.3; 3% of patients had scores of five to six. Approximately one-third of patients were on aspirin, and most procedures (89%) were classified as minor. Patients with mechanical heart valves, stroke/transient ischemic attack (TIA)/systemic embolization within 12 weeks, major bleeding within six weeks, renal insufficiency, thrombocytopenia or planned cardiac, intracranial, or intraspinal surgery were excluded.

Thirty-day incidence of arterial thromboembolism (stroke, TIA, systemic embolization) was 0.4% in the non-bridging group and 0.3% in the bridging group (P=0.01 for noninferiority). Patients suffering arterial thromboembolism had mean CHADS² scores of 2.6; most events occurred after minor procedures. Major bleeding was less common with no bridge (1.3% vs. 3.2%, relative risk 0.41, P=0.005 for superiority).

In this trial, most patients underwent minor procedures and few CHADS² 5-6 patients were enrolled; however, this well-designed, randomized trial adds important evidence to existing observational data.

Bottom line: Bridging is not warranted for most AF patients with CHADS2 scores of four or lower, at least for low-risk procedures.

Citation: Douketis JD, Spyropoulos AC, Kaatz S, et al. Perioperative bridging anticoagulation in patients with atrial fibrillation. N Engl J Med. 2015;373(9):823-833.

Three years ago, SHM launched Hospital Medicine Exchange (HMX), an online collaborative forum designed to foster thoughtful discussions related to the hospital medicine movement, facilitate networking among SHM members, and house shared resources and best practices in the field.

In celebration of this milestone, SHM has unveiled a new native mobile app for HMX, ensuring that SHM members have access to insight and answers from thousands of other members, wherever they are.

The redesigned app features a new user interface, including easy access to your communities as well as SHM’s website, social media, and The Hospital Leader blog. Not only is the new app easy to use, but, once you are online, you can be a part of the vibrant conversations taking place among thousands of hospitalists across the country.

After you download the new app from the iTunes or Google Play stores, log in using your SHM username and password on your tablet or smartphone to:

• Quickly scan through and engage in discussions in your favorite communities, including HMX Open Forum;
• Connect and network with fellow SHM members across the country by clicking on “People”;
• Check your private messages with Inbox; and
• Access resources relevant to your everyday practice in the Libraries.

“It is a great app, and I love the shortcuts on the home screen.” —Masoumeh Ghaffari, MD, hospitalist, Piedmont Healthcare, Acworth, Ga., in a posting to the HMX Open Forum

Members already are responding to the new and improved HMX mobile app. Hospitalist Masoumeh Ghaffari, MD of Piedmont Healthcare in Acworth, Ga., posted in HMX Open Forum, “It is a great app, and I love the shortcuts on the home screen.”

The new HMX mobile app is one of many recent HMX enhancements. HMX is constantly growing and launching new communities for members. For example, the Patient Experience community and the Women in Hospital Medicine community were most recently launched. Join these and other communities to share your thoughts on topics ranging from admissions to pediatrics and everything in between.

Get involved now by downloading the new app.

---

Brett Radler is SHM’s communications coordinator.

Three years ago, SHM launched Hospital Medicine Exchange (HMX), an online collaborative forum designed to foster thoughtful discussions related to the hospital medicine movement, facilitate networking among SHM members, and house shared resources and best practices in the field.

In celebration of this milestone, SHM has unveiled a new native mobile app for HMX, ensuring that SHM members have access to insight and answers from thousands of other members, wherever they are.

The redesigned app features a new user interface, including easy access to your communities as well as SHM’s website, social media, and The Hospital Leader blog. Not only is the new app easy to use, but, once you are online, you can be a part of the vibrant conversations taking place among thousands of hospitalists across the country.

After you download the new app from the iTunes or Google Play stores, log in using your SHM username and password on your tablet or smartphone to:

• Quickly scan through and engage in discussions in your favorite communities, including HMX Open Forum;
• Connect and network with fellow SHM members across the country by clicking on “People”;
• Check your private messages with Inbox; and
• Access resources relevant to your everyday practice in the Libraries.

“It is a great app, and I love the shortcuts on the home screen.” —Masoumeh Ghaffari, MD, hospitalist, Piedmont Healthcare, Acworth, Ga., in a posting to the HMX Open Forum

Members already are responding to the new and improved HMX mobile app. Hospitalist Masoumeh Ghaffari, MD of Piedmont Healthcare in Acworth, Ga., posted in HMX Open Forum, “It is a great app, and I love the shortcuts on the home screen.”

The new HMX mobile app is one of many recent HMX enhancements. HMX is constantly growing and launching new communities for members. For example, the Patient Experience community and the Women in Hospital Medicine community were most recently launched. Join these and other communities to share your thoughts on topics ranging from admissions to pediatrics and everything in between.

Get involved now by downloading the new app.

---

Brett Radler is SHM’s communications coordinator.

Three years ago, SHM launched Hospital Medicine Exchange (HMX), an online collaborative forum designed to foster thoughtful discussions related to the hospital medicine movement, facilitate networking among SHM members, and house shared resources and best practices in the field.

In celebration of this milestone, SHM has unveiled a new native mobile app for HMX, ensuring that SHM members have access to insight and answers from thousands of other members, wherever they are.

The redesigned app features a new user interface, including easy access to your communities as well as SHM’s website, social media, and The Hospital Leader blog. Not only is the new app easy to use, but, once you are online, you can be a part of the vibrant conversations taking place among thousands of hospitalists across the country.

After you download the new app from the iTunes or Google Play stores, log in using your SHM username and password on your tablet or smartphone to:

• Quickly scan through and engage in discussions in your favorite communities, including HMX Open Forum;
• Connect and network with fellow SHM members across the country by clicking on “People”;
• Check your private messages with Inbox; and
• Access resources relevant to your everyday practice in the Libraries.

“It is a great app, and I love the shortcuts on the home screen.” —Masoumeh Ghaffari, MD, hospitalist, Piedmont Healthcare, Acworth, Ga., in a posting to the HMX Open Forum

Members already are responding to the new and improved HMX mobile app. Hospitalist Masoumeh Ghaffari, MD of Piedmont Healthcare in Acworth, Ga., posted in HMX Open Forum, “It is a great app, and I love the shortcuts on the home screen.”

The new HMX mobile app is one of many recent HMX enhancements. HMX is constantly growing and launching new communities for members. For example, the Patient Experience community and the Women in Hospital Medicine community were most recently launched. Join these and other communities to share your thoughts on topics ranging from admissions to pediatrics and everything in between.

Get involved now by downloading the new app.

---

Brett Radler is SHM’s communications coordinator.

A quality improvement (QI) initiative can start with a single hospitalist, says Adam H. Corson, MD, a hospitalist at Seattle’s Swedish Medical Center.

In a study presented at SHM's annual meeting, Dr. Corson set out to determine whether critically evaluating how frequently common lab tests were ordered could help decrease hospital costs. Using a cohort of patients, Dr. Corson compared how often a complete blood count or a metabolic panel was ordered in a large hospitalist group. His QI intervention involved academic detailing, audit, and feedback, as well as transparent reporting of lab orders for 9,368 patients. At baseline, a mean of 2.06 common labs were ordered per patient day. The number of labs ordered post-intervention decreased by 10%.

“Within the hospitalist team itself, there was a 20% reduction,” Dr. Corson says. That percentage “got diluted down to 10% when you included all the other providers who care for a patient.” He found no adverse effects from this intervention on mortality, length-of-stay, or readmission rates. His report also cited a reduction in the volume of blood transfused per patient who received a transfusion and a $16.19 decrease in hospital costs—a total of $159,682—per admission annualized for the cohort.

Although better patient care was his main goal, a secondary goal was to demonstrate the potential value of hospitalists in today’s changing medical environment, particularly in terms of reimbursement. “In a fee-for-service world, hospitalists can’t participate as much as [physicians in] other areas of medicine,” he says. “But in a fee-for-outcome world, hospitalists can play a big role, and this is a demonstration of that.”

He also points out that this cost-effective intervention was basically done by him alone, “one hospitalist with access to electronic medical records and someone to pull some data out of there.”

Dr. Corson says he hopes his study will inspire other providers to look at this specific topic in their own practice and possibly expand it to other services they order each day. “The big headline these days is the United States spends more money on healthcare than everyone else does, but we don’t get better results,” he says. “Inherent in that is the idea that we do a lot of stuff that doesn’t need to be done or has no physical value. This is a small example of that.” TH

Visit our website for more information on other cost-cutting measures hospitalists can adopt.

A quality improvement (QI) initiative can start with a single hospitalist, says Adam H. Corson, MD, a hospitalist at Seattle’s Swedish Medical Center.

In a study presented at SHM's annual meeting, Dr. Corson set out to determine whether critically evaluating how frequently common lab tests were ordered could help decrease hospital costs. Using a cohort of patients, Dr. Corson compared how often a complete blood count or a metabolic panel was ordered in a large hospitalist group. His QI intervention involved academic detailing, audit, and feedback, as well as transparent reporting of lab orders for 9,368 patients. At baseline, a mean of 2.06 common labs were ordered per patient day. The number of labs ordered post-intervention decreased by 10%.

“Within the hospitalist team itself, there was a 20% reduction,” Dr. Corson says. That percentage “got diluted down to 10% when you included all the other providers who care for a patient.” He found no adverse effects from this intervention on mortality, length-of-stay, or readmission rates. His report also cited a reduction in the volume of blood transfused per patient who received a transfusion and a $16.19 decrease in hospital costs—a total of $159,682—per admission annualized for the cohort.

Although better patient care was his main goal, a secondary goal was to demonstrate the potential value of hospitalists in today’s changing medical environment, particularly in terms of reimbursement. “In a fee-for-service world, hospitalists can’t participate as much as [physicians in] other areas of medicine,” he says. “But in a fee-for-outcome world, hospitalists can play a big role, and this is a demonstration of that.”

He also points out that this cost-effective intervention was basically done by him alone, “one hospitalist with access to electronic medical records and someone to pull some data out of there.”

Dr. Corson says he hopes his study will inspire other providers to look at this specific topic in their own practice and possibly expand it to other services they order each day. “The big headline these days is the United States spends more money on healthcare than everyone else does, but we don’t get better results,” he says. “Inherent in that is the idea that we do a lot of stuff that doesn’t need to be done or has no physical value. This is a small example of that.” TH

Visit our website for more information on other cost-cutting measures hospitalists can adopt.

A quality improvement (QI) initiative can start with a single hospitalist, says Adam H. Corson, MD, a hospitalist at Seattle’s Swedish Medical Center.

In a study presented at SHM's annual meeting, Dr. Corson set out to determine whether critically evaluating how frequently common lab tests were ordered could help decrease hospital costs. Using a cohort of patients, Dr. Corson compared how often a complete blood count or a metabolic panel was ordered in a large hospitalist group. His QI intervention involved academic detailing, audit, and feedback, as well as transparent reporting of lab orders for 9,368 patients. At baseline, a mean of 2.06 common labs were ordered per patient day. The number of labs ordered post-intervention decreased by 10%.

“Within the hospitalist team itself, there was a 20% reduction,” Dr. Corson says. That percentage “got diluted down to 10% when you included all the other providers who care for a patient.” He found no adverse effects from this intervention on mortality, length-of-stay, or readmission rates. His report also cited a reduction in the volume of blood transfused per patient who received a transfusion and a $16.19 decrease in hospital costs—a total of $159,682—per admission annualized for the cohort.

Although better patient care was his main goal, a secondary goal was to demonstrate the potential value of hospitalists in today’s changing medical environment, particularly in terms of reimbursement. “In a fee-for-service world, hospitalists can’t participate as much as [physicians in] other areas of medicine,” he says. “But in a fee-for-outcome world, hospitalists can play a big role, and this is a demonstration of that.”

He also points out that this cost-effective intervention was basically done by him alone, “one hospitalist with access to electronic medical records and someone to pull some data out of there.”

Dr. Corson says he hopes his study will inspire other providers to look at this specific topic in their own practice and possibly expand it to other services they order each day. “The big headline these days is the United States spends more money on healthcare than everyone else does, but we don’t get better results,” he says. “Inherent in that is the idea that we do a lot of stuff that doesn’t need to be done or has no physical value. This is a small example of that.” TH

Visit our website for more information on other cost-cutting measures hospitalists can adopt.

What do Clostridium difficile, Staphylococcus aureus, and acute pulmonary embolism have in common? They were all topics of discussion at the 2015 Mid-Atlantic Hospital Medicine Symposium, held at the Icahn School of Medicine at Mount Sinai in New York City.

Vikas Saini, MD, FACC, president of the Lown Institute in Brookline, Mass., and associate physician at Brigham and Women’s Hospital in Boston, gave the keynote address on high-value care.

“We’re asking you to do hard things: to be kind to complete strangers, to feel their pain, to be compassionate when you’re on the run,” Dr. Saini said as he urged his fellow physicians to be more personable with patients. “Pull up a chair and sit down. It takes you 30 seconds, but for the patient, it feels like an eternity.” Dr. Saini, a guest lecturer at the symposium, also stressed the importance of being collaborative and encouraged clinicians to join their colleagues in implementing RightCare Rounds.

Following the keynote address, Louis DePalo, MD, an associate professor of pulmonary, critical care, and sleep at Icahn School of Medicine, gave a 30-minute presentation on the management of acute pulmonary embolism (PE). 

Dr. DePalo said that in his early days of practicing medicine, PE patients were usually hospitalized without debate. Today, thanks to indices such as the Pulmonary Embolism Severity Index, there are algorithms to determine the severity of PE in patients, allowing doctors to determine whether patients should be discharged or hospitalized. Still, Dr. DePalo added, “Discussions about sending a patient home are complicated.”

If a patient has severe PE, Dr. DePalo advised doctors to analyze studies such as the Pulmonary Embolism Thrombolysis (PEITHO) trial and the Moderate Pulmonary Embolism Treated with Thrombolysis (MOPPETT) trial to determine when to use advanced treatments. “One study may not be sufficient for administering advanced therapies,” Dr. DePalo said. “One study doesn’t make us feel good, so get a lot of data.”

After Dr. DePalo’s presentation, physicians gave presentations on common healthcare-associated infections. Gopi Patel, MD, an assistant professor of infectious diseases at Icahn School of Medicine, discussed Clostridium difficile infection (CDI). “CDI is the most common [healthcare-associated infection] in the United States,” Dr. Patel said as she urged physicians to “be a role model” by practicing good hand hygiene.

Using the updated practice guidelines from the Infectious Diseases Society of America, Tim Sullivan, MD, an assistant professor of infectious diseases at Icahn School of Medicine, discussed skin and soft tissue infections, particularly methicillin-resistant Staphylococcus aureus (MRSA). The guidelines “make a very important distinction between purulent and nonpurulent infections,” Dr. Sullivan said. “The majority of nonpurulent infections are caused by strep, [and] treating for strep seems to be sufficient to cure the infection … Adding extra coverage for MRSA is either not helpful or may actually be harmful to patients.”

Purulent infections, which require drainage, “are mostly caused by Staph aureus, including MRSA,” Dr. Sullivan said. “You don’t always have to give antibiotics, but they are recommended when the patient is sick.”

Dr. Sullivan said although “it can be sort of confusing trying to choose the right antibiotics for your patient … almost everyone should just receive vancomycin.” The drug is well-studied, inexpensive at $2.80 per dose for a five-day treatment, and well-tolerated by patients, he added. Yet vancomycin should not be administered to everyone as some patients experience devastating adverse reactions, and vancomycin could potentially cause irreversible hearing loss, he said.

Dr. Sullivan mentioned three new antibiotic treatments for MRSA: telavancin, which the U.S. Food and Drug Administration approved in 2009, costs 75 times more than vancomycin; dalbavancin, which was approved last May, costs $5,300 for two doses; and oritavancin, which was approved last August, costs $3,400 for one dose.

 

The arguments for using these newer drugs “may be that you can discharge the patient home, assuming they’ll have an active antibiotic in their system for a week, and maybe that will be more cost-effective,” Dr. Sullivan said. “The role that these should play in the management of your inpatients is still not clear, but they’re very new and interesting developments in treatment.” TH

Visit our website for more information on antibiotic stewardship and hospitalists.

What do Clostridium difficile, Staphylococcus aureus, and acute pulmonary embolism have in common? They were all topics of discussion at the 2015 Mid-Atlantic Hospital Medicine Symposium, held at the Icahn School of Medicine at Mount Sinai in New York City.

Vikas Saini, MD, FACC, president of the Lown Institute in Brookline, Mass., and associate physician at Brigham and Women’s Hospital in Boston, gave the keynote address on high-value care.

“We’re asking you to do hard things: to be kind to complete strangers, to feel their pain, to be compassionate when you’re on the run,” Dr. Saini said as he urged his fellow physicians to be more personable with patients. “Pull up a chair and sit down. It takes you 30 seconds, but for the patient, it feels like an eternity.” Dr. Saini, a guest lecturer at the symposium, also stressed the importance of being collaborative and encouraged clinicians to join their colleagues in implementing RightCare Rounds.

Following the keynote address, Louis DePalo, MD, an associate professor of pulmonary, critical care, and sleep at Icahn School of Medicine, gave a 30-minute presentation on the management of acute pulmonary embolism (PE). 

Dr. DePalo said that in his early days of practicing medicine, PE patients were usually hospitalized without debate. Today, thanks to indices such as the Pulmonary Embolism Severity Index, there are algorithms to determine the severity of PE in patients, allowing doctors to determine whether patients should be discharged or hospitalized. Still, Dr. DePalo added, “Discussions about sending a patient home are complicated.”

If a patient has severe PE, Dr. DePalo advised doctors to analyze studies such as the Pulmonary Embolism Thrombolysis (PEITHO) trial and the Moderate Pulmonary Embolism Treated with Thrombolysis (MOPPETT) trial to determine when to use advanced treatments. “One study may not be sufficient for administering advanced therapies,” Dr. DePalo said. “One study doesn’t make us feel good, so get a lot of data.”

After Dr. DePalo’s presentation, physicians gave presentations on common healthcare-associated infections. Gopi Patel, MD, an assistant professor of infectious diseases at Icahn School of Medicine, discussed Clostridium difficile infection (CDI). “CDI is the most common [healthcare-associated infection] in the United States,” Dr. Patel said as she urged physicians to “be a role model” by practicing good hand hygiene.

Using the updated practice guidelines from the Infectious Diseases Society of America, Tim Sullivan, MD, an assistant professor of infectious diseases at Icahn School of Medicine, discussed skin and soft tissue infections, particularly methicillin-resistant Staphylococcus aureus (MRSA). The guidelines “make a very important distinction between purulent and nonpurulent infections,” Dr. Sullivan said. “The majority of nonpurulent infections are caused by strep, [and] treating for strep seems to be sufficient to cure the infection … Adding extra coverage for MRSA is either not helpful or may actually be harmful to patients.”

Purulent infections, which require drainage, “are mostly caused by Staph aureus, including MRSA,” Dr. Sullivan said. “You don’t always have to give antibiotics, but they are recommended when the patient is sick.”

Dr. Sullivan said although “it can be sort of confusing trying to choose the right antibiotics for your patient … almost everyone should just receive vancomycin.” The drug is well-studied, inexpensive at $2.80 per dose for a five-day treatment, and well-tolerated by patients, he added. Yet vancomycin should not be administered to everyone as some patients experience devastating adverse reactions, and vancomycin could potentially cause irreversible hearing loss, he said.

Dr. Sullivan mentioned three new antibiotic treatments for MRSA: telavancin, which the U.S. Food and Drug Administration approved in 2009, costs 75 times more than vancomycin; dalbavancin, which was approved last May, costs $5,300 for two doses; and oritavancin, which was approved last August, costs $3,400 for one dose.

 

The arguments for using these newer drugs “may be that you can discharge the patient home, assuming they’ll have an active antibiotic in their system for a week, and maybe that will be more cost-effective,” Dr. Sullivan said. “The role that these should play in the management of your inpatients is still not clear, but they’re very new and interesting developments in treatment.” TH

Visit our website for more information on antibiotic stewardship and hospitalists.

What do Clostridium difficile, Staphylococcus aureus, and acute pulmonary embolism have in common? They were all topics of discussion at the 2015 Mid-Atlantic Hospital Medicine Symposium, held at the Icahn School of Medicine at Mount Sinai in New York City.

Vikas Saini, MD, FACC, president of the Lown Institute in Brookline, Mass., and associate physician at Brigham and Women’s Hospital in Boston, gave the keynote address on high-value care.

“We’re asking you to do hard things: to be kind to complete strangers, to feel their pain, to be compassionate when you’re on the run,” Dr. Saini said as he urged his fellow physicians to be more personable with patients. “Pull up a chair and sit down. It takes you 30 seconds, but for the patient, it feels like an eternity.” Dr. Saini, a guest lecturer at the symposium, also stressed the importance of being collaborative and encouraged clinicians to join their colleagues in implementing RightCare Rounds.

Following the keynote address, Louis DePalo, MD, an associate professor of pulmonary, critical care, and sleep at Icahn School of Medicine, gave a 30-minute presentation on the management of acute pulmonary embolism (PE). 

Dr. DePalo said that in his early days of practicing medicine, PE patients were usually hospitalized without debate. Today, thanks to indices such as the Pulmonary Embolism Severity Index, there are algorithms to determine the severity of PE in patients, allowing doctors to determine whether patients should be discharged or hospitalized. Still, Dr. DePalo added, “Discussions about sending a patient home are complicated.”

If a patient has severe PE, Dr. DePalo advised doctors to analyze studies such as the Pulmonary Embolism Thrombolysis (PEITHO) trial and the Moderate Pulmonary Embolism Treated with Thrombolysis (MOPPETT) trial to determine when to use advanced treatments. “One study may not be sufficient for administering advanced therapies,” Dr. DePalo said. “One study doesn’t make us feel good, so get a lot of data.”

After Dr. DePalo’s presentation, physicians gave presentations on common healthcare-associated infections. Gopi Patel, MD, an assistant professor of infectious diseases at Icahn School of Medicine, discussed Clostridium difficile infection (CDI). “CDI is the most common [healthcare-associated infection] in the United States,” Dr. Patel said as she urged physicians to “be a role model” by practicing good hand hygiene.

Using the updated practice guidelines from the Infectious Diseases Society of America, Tim Sullivan, MD, an assistant professor of infectious diseases at Icahn School of Medicine, discussed skin and soft tissue infections, particularly methicillin-resistant Staphylococcus aureus (MRSA). The guidelines “make a very important distinction between purulent and nonpurulent infections,” Dr. Sullivan said. “The majority of nonpurulent infections are caused by strep, [and] treating for strep seems to be sufficient to cure the infection … Adding extra coverage for MRSA is either not helpful or may actually be harmful to patients.”

Purulent infections, which require drainage, “are mostly caused by Staph aureus, including MRSA,” Dr. Sullivan said. “You don’t always have to give antibiotics, but they are recommended when the patient is sick.”

Dr. Sullivan said although “it can be sort of confusing trying to choose the right antibiotics for your patient … almost everyone should just receive vancomycin.” The drug is well-studied, inexpensive at $2.80 per dose for a five-day treatment, and well-tolerated by patients, he added. Yet vancomycin should not be administered to everyone as some patients experience devastating adverse reactions, and vancomycin could potentially cause irreversible hearing loss, he said.

Dr. Sullivan mentioned three new antibiotic treatments for MRSA: telavancin, which the U.S. Food and Drug Administration approved in 2009, costs 75 times more than vancomycin; dalbavancin, which was approved last May, costs $5,300 for two doses; and oritavancin, which was approved last August, costs $3,400 for one dose.

 

The arguments for using these newer drugs “may be that you can discharge the patient home, assuming they’ll have an active antibiotic in their system for a week, and maybe that will be more cost-effective,” Dr. Sullivan said. “The role that these should play in the management of your inpatients is still not clear, but they’re very new and interesting developments in treatment.” TH

Visit our website for more information on antibiotic stewardship and hospitalists.

Hospitalists are charged with giving the best of care and treatment, regardless of whether or not a patient is insured or has a PCP to transition to after discharge. But patients who do not have insurance or a PCP pose many challenges to hospitalists, as well as the healthcare systems they work in. Although some hospitals and health systems have found ways to address these challenges, issues persist, with high costs to care for these patients topping the list. In 2013, the cost of community hospitals’ uncompensated care climbed to $46.4 billion.¹

Typically, undocumented and unassigned patients face many social and economic challenges. Many of these patients are unemployed or work as independent contractors without employer-offered health insurance. Some have multiple jobs, can’t take time off from work for doctor appointments, or are undocumented workers.

More patients have acquired health insurance in recent years as a result of the Affordable Care Act (ACA) and Medicaid expansion; however, some eligible people never complete the necessary forms.

With or without insurance, some patients don’t establish primary care because they have been healthy, have difficulty navigating the healthcare system, lack transportation, or desire more culturally tailored care. Some Medicare and Medicaid patients don’t have a PCP in their community who accepts these programs.

Treatment Challenges

Uninsured patients often are sicker and have more complex conditions than those with insurance, according to Beth Feldpush, DrPH, senior vice president of policy and advocacy at the nonprofit trade group America’s Essential Hospitals, which is based in Washington, D.C., and represents 250 safety net hospitals throughout the U.S.

“Because they can’t afford regular preventive and primary care, they forgo needed healthcare services until their conditions worsen and they require costly hospital care,” says Dr. Feldpush. Uninsured patients often lack the resources for follow-up care to help them recover and stay well. She says more than half of all inpatient discharges and outpatient visits at her groups’ hospitals are for uninsured or Medicaid patients.

When an uninsured patient is discharged from the hospital, finding follow-up care can be difficult.

“Their ability to get an appointment to see a PCP is extremely limited, because many providers don’t see patients without health insurance,” says Scott Sears, MD, MBA, chief clinical officer of Tacoma, Wash.-based Sound Physicians. Dr. Sears notes that in some hospitalist programs, as many as 40% of hospitalized patients lack insurance. “But without secured follow-up care, hospitalists are hesitant to send patients home, because they could relapse.”

Typically, these patients are not completely well and should be transferred to a skilled nursing or hospice facility; however, many facilities won’t accept them without insurance. Often, these patients need a PCP to monitor them with laboratory tests and other follow-up tests, to prescribe and monitor medications, and to ensure that they are following their plan of care.

At some medical facilities, subspecialists who consult on patients may screen them and refuse to see anyone without health insurance.

“So even though some patients may need subspecialty support, they may not have access to it,” Dr. Sears says. “While some patients without insurance qualify for Medicaid or other programs, due to the amount of paperwork and time to enroll, they end up staying in the hospital even though they are ready for discharge.”

Transitional Challenges

Most patients admitted to the hospital either have exacerbations of chronic conditions or a new diagnosis. “It’s rare to hospitalize a patient with a discrete illness that wouldn’t need care after discharge, so having a robust PCP partner is critical to a patient’s health,” says Honora Englander, MD, medical director of the Care Transitions Innovation (C-TRAIN) program at Oregon Health and Science University (OHSU) in Portland. For many patients, psychosocial complexity complicates their transition out of the hospital. An effective system needs to address a patient’s mental health, housing, and other social needs.

 

It may take four to six weeks for a patient without an established PCP to get a new patient appointment. “This is a huge impediment, as the patient won’t have anyone to ensure that he or she continues along the proper care path,” Dr. Sears says.

“Studies estimate that more than half of medication errors that patients experience occur during transitions and after discharge,” Dr. Sears says.² “Intervention with a healthcare provider who can review proper use after discharge can dramatically reduce errors and [improve] patient outcomes.”

Rates of patients without a PCP vary by region for Sound Physicians. In the northwest region, about 25% of admitted patients lack a PCP; in the gulf region, the figure can be as high as 60%.

“In Texas, there is a large number of patients and not as many PCPs,” he adds. “There is also a larger percentage of patients without health insurance. Sometimes patients have coverage but have never established care with a PCP.”

As a result of not having a PCP to transition to, some patients return to the hospital soon after discharge, Dr. Feldpush notes.

Tips for Treating Uninsured Patients

Some facilities have found successful ways to help hospitalized patients without health insurance. Dr. Sears says that hospitalists can investigate which clinics accept uninsured patients or which local physician groups are willing to see them after discharge, in exchange for hospitalists taking care of them in the hospital. They also can investigate the community-based insurance programs that are available.

Teresa Coker, MSN, ARNP, FNP-BC, a Sound Physicians program manager at Mercy Medical Center in Cedar Rapids, Iowa, says that when patients lack insurance at her hospital, an organization will review the patient’s case, determine insurance eligibility, and assist the patient in completing the appropriate paperwork. When patients are not eligible, they are instructed to inquire about the hospital’s charity care program if they receive a bill they are unable to pay.

In addition, the community has a free health clinic that serves those without insurance. “Patients are given the address and hours prior to discharge, because it is walk-in only,” Coker says. “All patients are recommended to follow up within one week, or sooner if medications are needed.”

Dr. Englander advocates that physicians take into account medication costs, transportation, and other social considerations when planning care after hospitalization. The team at OHSU developed a low-cost formulary (based in part on widely available $4 plans from national pharmacy chains), and OHSU provides medications for uninsured patients in the program for up to 30 days following discharge.

For patients who can’t afford the $4 drug plan, case managers offer coupons for $4 prescriptions, says Malik Merchant, MD, area medical officer for the Schumachergroup in Harker Heights, Texas. He says that as many as 30% of the patients in his area are undocumented or unassigned. For more expensive medications, a social worker offers pharmaceutical company coupons when they are available. The institution also has a small budget to pay for drugs.

Dr. Merchant has found the biggest challenge to be the transition of care from inpatient to outpatient.

“Case managers and social workers prepare a financial worksheet that provides the possibility of overall cost savings for the institution, if patients are willing to participate in some upfront cost,” he says. “When our parent institution came on board, we developed contracts with local pharmacies, [a] skilled nursing facility, and PCPs to take these patients until they recovered from an acute illness. Our institution paid for these services at a reduced rate but saved money by reducing the length of their hospital stay.”

 

Dr. Feldpush says her group’s hospitals work hard to reach the uninsured. South Florida’s Memorial Healthcare System (MHS) created the Health Intervention with Targeted Services (HITS) Program, an outreach initiative that links patients with insurance programs or medical homes.³ The HITS team used a geographic information system map to target 15 neighborhoods with the highest rates of hospitalized, uninsured patients. Over a six-month period, the team approached these neighborhoods using various outreach strategies, such as health fairs, educational workshops, and door-to-door visits.³

Approximately 6,910 HITS participants have been enrolled in Medicaid, Florida’s children’s health insurance program, or an MHS community health center. Over a three-year study period, MHS saved $284,856 in the ED, about $2.8 million in inpatient costs, and roughly $4 million overall.³

Barriers to Follow-Up Care

Whether you are looking to help uninsured patients, those without a PCP, or both, the key is to try to fill in the gaps.

“As hospitalists, we need to work with pharmacists, case managers and social workers, and others to identify affordable and effective ways to provide care,” Dr. Englander says. “Interprofessional team members, community partners, and family members can help hospitalists understand patient and population health needs and available resources.”

In an effort to close transitional care gaps, OHSU developed the C-TRAIN program, a multi-component transitional care intervention that includes four main elements:

1. Transitional care nurse who sees patients in the hospital, makes home visits, and helps coordinate care 30 days post-discharge;
2. Inpatient pharmacy consultation and prescription medications at discharge from a low-cost, value-based formulary;
3. Medical home linkages, whereby OHSU partners with and provides payment to three community clinics to provide primary care for uninsured patients; and
4. Monthly implementation team meetings that convene diverse healthcare stakeholders to integrate elements of the healthcare system and engage in ongoing quality improvement.

The Schumachergroup has also found an effective solution.

“The department head of our case managers and social workers made an agreement with a local multispecialty group,” Dr. Merchant says. “The group agreed to take all discharged patients and be their PCP for 30 days, even if the patient couldn’t pay, in exchange for receiving all patients who had good insurance but did not have an established PCP.

“This has worked well. Every patient discharged from our facility has a PCP listed at discharge, and the unit clerk makes an appointment and documents it in the electronic medical record.”

Sound Physicians has set up a service line, called transitional care services, to smooth transitions of care after discharge for up to 90 days, depending on their clinical needs. It hires providers who work in post-acute facilities and who can also visit patients at home. After discharge, a nurse practitioner will visit the patient, connect him or her with a PCP, and get the patient access to care.

“Smaller hospitalist groups could set up post-discharge clinics,” Dr. Sears suggests, “so when they discharge a patient without a PCP, [the patient] could return to see one of the hospitalists there.”

Mount Carmel East Hospital, a Sound Physicians’ hospital in Columbus, Ohio, has a financial assistance program.

“The case management department provides community health resources to patients who are insured but have no PCP,” says Shelli Morris, RN. “We also have a hotline that patients can call for a list of PCPs that are accepting new patients.”

When a patient lacks insurance or a PCP, Morris is contacted by the physician or case management to provide a referral to a neighborhood health clinic. “Then, as a courtesy, we set up a post-hospital follow-up appointment,” she says.

 

By working with other care team members at facilities such as outpatient clinics and pharmacies, hospitalists and other staff have been able to improve care for patients without insurance or a PCP after discharge. Knowing the funding that is available, as well as programs to help these patients, is also integral.

---

Karen Appold is a medical writer in Pennsylvania.

References

1. American Hospital Association. American Hospital Association Uncompensated Hospital Care Cost Fact Sheet. Accessed October 8, 2015.
2. The Office of the National Coordinator for Health Information Technology. Health IT in long-term and post acute care: issue brief. March 15, 2013. Accessed October 8, 2015.
3. Addison E. Gage award winner HITS the streets to connect with the uninsured. America’s Essential Hospitals. July 22, 2014. Accessed October 8, 2015.
4. DeNavas C, Proctor BD, Smith JC. Income, poverty, and health insurance coverage in the United States: 2010. United States Census Bureau. September 2011. Accessed October 8, 2015.
5. United States Census Bureau. People without health insurance coverage by selected characteristics: 2010 and 2011. Accessed October 8, 2015.
6. Coughlin TA, Holahan J, Caswell K, McGrath M. Uncompensated care for the uninsured in 2013: a detailed examination. The Henry J. Kaiser Family Foundation. May 30, 2014. Accessed October 8, 2015.

Hospitalists are charged with giving the best of care and treatment, regardless of whether or not a patient is insured or has a PCP to transition to after discharge. But patients who do not have insurance or a PCP pose many challenges to hospitalists, as well as the healthcare systems they work in. Although some hospitals and health systems have found ways to address these challenges, issues persist, with high costs to care for these patients topping the list. In 2013, the cost of community hospitals’ uncompensated care climbed to $46.4 billion.¹

Typically, undocumented and unassigned patients face many social and economic challenges. Many of these patients are unemployed or work as independent contractors without employer-offered health insurance. Some have multiple jobs, can’t take time off from work for doctor appointments, or are undocumented workers.

More patients have acquired health insurance in recent years as a result of the Affordable Care Act (ACA) and Medicaid expansion; however, some eligible people never complete the necessary forms.

With or without insurance, some patients don’t establish primary care because they have been healthy, have difficulty navigating the healthcare system, lack transportation, or desire more culturally tailored care. Some Medicare and Medicaid patients don’t have a PCP in their community who accepts these programs.

Treatment Challenges

Uninsured patients often are sicker and have more complex conditions than those with insurance, according to Beth Feldpush, DrPH, senior vice president of policy and advocacy at the nonprofit trade group America’s Essential Hospitals, which is based in Washington, D.C., and represents 250 safety net hospitals throughout the U.S.

“Because they can’t afford regular preventive and primary care, they forgo needed healthcare services until their conditions worsen and they require costly hospital care,” says Dr. Feldpush. Uninsured patients often lack the resources for follow-up care to help them recover and stay well. She says more than half of all inpatient discharges and outpatient visits at her groups’ hospitals are for uninsured or Medicaid patients.

When an uninsured patient is discharged from the hospital, finding follow-up care can be difficult.

“Their ability to get an appointment to see a PCP is extremely limited, because many providers don’t see patients without health insurance,” says Scott Sears, MD, MBA, chief clinical officer of Tacoma, Wash.-based Sound Physicians. Dr. Sears notes that in some hospitalist programs, as many as 40% of hospitalized patients lack insurance. “But without secured follow-up care, hospitalists are hesitant to send patients home, because they could relapse.”

Typically, these patients are not completely well and should be transferred to a skilled nursing or hospice facility; however, many facilities won’t accept them without insurance. Often, these patients need a PCP to monitor them with laboratory tests and other follow-up tests, to prescribe and monitor medications, and to ensure that they are following their plan of care.

At some medical facilities, subspecialists who consult on patients may screen them and refuse to see anyone without health insurance.

“So even though some patients may need subspecialty support, they may not have access to it,” Dr. Sears says. “While some patients without insurance qualify for Medicaid or other programs, due to the amount of paperwork and time to enroll, they end up staying in the hospital even though they are ready for discharge.”

Transitional Challenges

Most patients admitted to the hospital either have exacerbations of chronic conditions or a new diagnosis. “It’s rare to hospitalize a patient with a discrete illness that wouldn’t need care after discharge, so having a robust PCP partner is critical to a patient’s health,” says Honora Englander, MD, medical director of the Care Transitions Innovation (C-TRAIN) program at Oregon Health and Science University (OHSU) in Portland. For many patients, psychosocial complexity complicates their transition out of the hospital. An effective system needs to address a patient’s mental health, housing, and other social needs.

 

It may take four to six weeks for a patient without an established PCP to get a new patient appointment. “This is a huge impediment, as the patient won’t have anyone to ensure that he or she continues along the proper care path,” Dr. Sears says.

“Studies estimate that more than half of medication errors that patients experience occur during transitions and after discharge,” Dr. Sears says.² “Intervention with a healthcare provider who can review proper use after discharge can dramatically reduce errors and [improve] patient outcomes.”

Rates of patients without a PCP vary by region for Sound Physicians. In the northwest region, about 25% of admitted patients lack a PCP; in the gulf region, the figure can be as high as 60%.

“In Texas, there is a large number of patients and not as many PCPs,” he adds. “There is also a larger percentage of patients without health insurance. Sometimes patients have coverage but have never established care with a PCP.”

As a result of not having a PCP to transition to, some patients return to the hospital soon after discharge, Dr. Feldpush notes.

Tips for Treating Uninsured Patients

Some facilities have found successful ways to help hospitalized patients without health insurance. Dr. Sears says that hospitalists can investigate which clinics accept uninsured patients or which local physician groups are willing to see them after discharge, in exchange for hospitalists taking care of them in the hospital. They also can investigate the community-based insurance programs that are available.

Teresa Coker, MSN, ARNP, FNP-BC, a Sound Physicians program manager at Mercy Medical Center in Cedar Rapids, Iowa, says that when patients lack insurance at her hospital, an organization will review the patient’s case, determine insurance eligibility, and assist the patient in completing the appropriate paperwork. When patients are not eligible, they are instructed to inquire about the hospital’s charity care program if they receive a bill they are unable to pay.

In addition, the community has a free health clinic that serves those without insurance. “Patients are given the address and hours prior to discharge, because it is walk-in only,” Coker says. “All patients are recommended to follow up within one week, or sooner if medications are needed.”

Dr. Englander advocates that physicians take into account medication costs, transportation, and other social considerations when planning care after hospitalization. The team at OHSU developed a low-cost formulary (based in part on widely available $4 plans from national pharmacy chains), and OHSU provides medications for uninsured patients in the program for up to 30 days following discharge.

For patients who can’t afford the $4 drug plan, case managers offer coupons for $4 prescriptions, says Malik Merchant, MD, area medical officer for the Schumachergroup in Harker Heights, Texas. He says that as many as 30% of the patients in his area are undocumented or unassigned. For more expensive medications, a social worker offers pharmaceutical company coupons when they are available. The institution also has a small budget to pay for drugs.

Dr. Merchant has found the biggest challenge to be the transition of care from inpatient to outpatient.

“Case managers and social workers prepare a financial worksheet that provides the possibility of overall cost savings for the institution, if patients are willing to participate in some upfront cost,” he says. “When our parent institution came on board, we developed contracts with local pharmacies, [a] skilled nursing facility, and PCPs to take these patients until they recovered from an acute illness. Our institution paid for these services at a reduced rate but saved money by reducing the length of their hospital stay.”

 

Dr. Feldpush says her group’s hospitals work hard to reach the uninsured. South Florida’s Memorial Healthcare System (MHS) created the Health Intervention with Targeted Services (HITS) Program, an outreach initiative that links patients with insurance programs or medical homes.³ The HITS team used a geographic information system map to target 15 neighborhoods with the highest rates of hospitalized, uninsured patients. Over a six-month period, the team approached these neighborhoods using various outreach strategies, such as health fairs, educational workshops, and door-to-door visits.³

Approximately 6,910 HITS participants have been enrolled in Medicaid, Florida’s children’s health insurance program, or an MHS community health center. Over a three-year study period, MHS saved $284,856 in the ED, about $2.8 million in inpatient costs, and roughly $4 million overall.³

Barriers to Follow-Up Care

Whether you are looking to help uninsured patients, those without a PCP, or both, the key is to try to fill in the gaps.

“As hospitalists, we need to work with pharmacists, case managers and social workers, and others to identify affordable and effective ways to provide care,” Dr. Englander says. “Interprofessional team members, community partners, and family members can help hospitalists understand patient and population health needs and available resources.”

In an effort to close transitional care gaps, OHSU developed the C-TRAIN program, a multi-component transitional care intervention that includes four main elements:

1. Transitional care nurse who sees patients in the hospital, makes home visits, and helps coordinate care 30 days post-discharge;
2. Inpatient pharmacy consultation and prescription medications at discharge from a low-cost, value-based formulary;
3. Medical home linkages, whereby OHSU partners with and provides payment to three community clinics to provide primary care for uninsured patients; and
4. Monthly implementation team meetings that convene diverse healthcare stakeholders to integrate elements of the healthcare system and engage in ongoing quality improvement.

The Schumachergroup has also found an effective solution.

“The department head of our case managers and social workers made an agreement with a local multispecialty group,” Dr. Merchant says. “The group agreed to take all discharged patients and be their PCP for 30 days, even if the patient couldn’t pay, in exchange for receiving all patients who had good insurance but did not have an established PCP.

“This has worked well. Every patient discharged from our facility has a PCP listed at discharge, and the unit clerk makes an appointment and documents it in the electronic medical record.”

Sound Physicians has set up a service line, called transitional care services, to smooth transitions of care after discharge for up to 90 days, depending on their clinical needs. It hires providers who work in post-acute facilities and who can also visit patients at home. After discharge, a nurse practitioner will visit the patient, connect him or her with a PCP, and get the patient access to care.

“Smaller hospitalist groups could set up post-discharge clinics,” Dr. Sears suggests, “so when they discharge a patient without a PCP, [the patient] could return to see one of the hospitalists there.”

Mount Carmel East Hospital, a Sound Physicians’ hospital in Columbus, Ohio, has a financial assistance program.

“The case management department provides community health resources to patients who are insured but have no PCP,” says Shelli Morris, RN. “We also have a hotline that patients can call for a list of PCPs that are accepting new patients.”

When a patient lacks insurance or a PCP, Morris is contacted by the physician or case management to provide a referral to a neighborhood health clinic. “Then, as a courtesy, we set up a post-hospital follow-up appointment,” she says.

 

By working with other care team members at facilities such as outpatient clinics and pharmacies, hospitalists and other staff have been able to improve care for patients without insurance or a PCP after discharge. Knowing the funding that is available, as well as programs to help these patients, is also integral.

---

Karen Appold is a medical writer in Pennsylvania.

References

1. American Hospital Association. American Hospital Association Uncompensated Hospital Care Cost Fact Sheet. Accessed October 8, 2015.
2. The Office of the National Coordinator for Health Information Technology. Health IT in long-term and post acute care: issue brief. March 15, 2013. Accessed October 8, 2015.
3. Addison E. Gage award winner HITS the streets to connect with the uninsured. America’s Essential Hospitals. July 22, 2014. Accessed October 8, 2015.
4. DeNavas C, Proctor BD, Smith JC. Income, poverty, and health insurance coverage in the United States: 2010. United States Census Bureau. September 2011. Accessed October 8, 2015.
5. United States Census Bureau. People without health insurance coverage by selected characteristics: 2010 and 2011. Accessed October 8, 2015.
6. Coughlin TA, Holahan J, Caswell K, McGrath M. Uncompensated care for the uninsured in 2013: a detailed examination. The Henry J. Kaiser Family Foundation. May 30, 2014. Accessed October 8, 2015.

Hospitalists are charged with giving the best of care and treatment, regardless of whether or not a patient is insured or has a PCP to transition to after discharge. But patients who do not have insurance or a PCP pose many challenges to hospitalists, as well as the healthcare systems they work in. Although some hospitals and health systems have found ways to address these challenges, issues persist, with high costs to care for these patients topping the list. In 2013, the cost of community hospitals’ uncompensated care climbed to $46.4 billion.¹

Typically, undocumented and unassigned patients face many social and economic challenges. Many of these patients are unemployed or work as independent contractors without employer-offered health insurance. Some have multiple jobs, can’t take time off from work for doctor appointments, or are undocumented workers.

More patients have acquired health insurance in recent years as a result of the Affordable Care Act (ACA) and Medicaid expansion; however, some eligible people never complete the necessary forms.

With or without insurance, some patients don’t establish primary care because they have been healthy, have difficulty navigating the healthcare system, lack transportation, or desire more culturally tailored care. Some Medicare and Medicaid patients don’t have a PCP in their community who accepts these programs.

Treatment Challenges

Uninsured patients often are sicker and have more complex conditions than those with insurance, according to Beth Feldpush, DrPH, senior vice president of policy and advocacy at the nonprofit trade group America’s Essential Hospitals, which is based in Washington, D.C., and represents 250 safety net hospitals throughout the U.S.

“Because they can’t afford regular preventive and primary care, they forgo needed healthcare services until their conditions worsen and they require costly hospital care,” says Dr. Feldpush. Uninsured patients often lack the resources for follow-up care to help them recover and stay well. She says more than half of all inpatient discharges and outpatient visits at her groups’ hospitals are for uninsured or Medicaid patients.

When an uninsured patient is discharged from the hospital, finding follow-up care can be difficult.

“Their ability to get an appointment to see a PCP is extremely limited, because many providers don’t see patients without health insurance,” says Scott Sears, MD, MBA, chief clinical officer of Tacoma, Wash.-based Sound Physicians. Dr. Sears notes that in some hospitalist programs, as many as 40% of hospitalized patients lack insurance. “But without secured follow-up care, hospitalists are hesitant to send patients home, because they could relapse.”

Typically, these patients are not completely well and should be transferred to a skilled nursing or hospice facility; however, many facilities won’t accept them without insurance. Often, these patients need a PCP to monitor them with laboratory tests and other follow-up tests, to prescribe and monitor medications, and to ensure that they are following their plan of care.

At some medical facilities, subspecialists who consult on patients may screen them and refuse to see anyone without health insurance.

“So even though some patients may need subspecialty support, they may not have access to it,” Dr. Sears says. “While some patients without insurance qualify for Medicaid or other programs, due to the amount of paperwork and time to enroll, they end up staying in the hospital even though they are ready for discharge.”

Transitional Challenges

Most patients admitted to the hospital either have exacerbations of chronic conditions or a new diagnosis. “It’s rare to hospitalize a patient with a discrete illness that wouldn’t need care after discharge, so having a robust PCP partner is critical to a patient’s health,” says Honora Englander, MD, medical director of the Care Transitions Innovation (C-TRAIN) program at Oregon Health and Science University (OHSU) in Portland. For many patients, psychosocial complexity complicates their transition out of the hospital. An effective system needs to address a patient’s mental health, housing, and other social needs.

 

It may take four to six weeks for a patient without an established PCP to get a new patient appointment. “This is a huge impediment, as the patient won’t have anyone to ensure that he or she continues along the proper care path,” Dr. Sears says.

“Studies estimate that more than half of medication errors that patients experience occur during transitions and after discharge,” Dr. Sears says.² “Intervention with a healthcare provider who can review proper use after discharge can dramatically reduce errors and [improve] patient outcomes.”

Rates of patients without a PCP vary by region for Sound Physicians. In the northwest region, about 25% of admitted patients lack a PCP; in the gulf region, the figure can be as high as 60%.

“In Texas, there is a large number of patients and not as many PCPs,” he adds. “There is also a larger percentage of patients without health insurance. Sometimes patients have coverage but have never established care with a PCP.”

As a result of not having a PCP to transition to, some patients return to the hospital soon after discharge, Dr. Feldpush notes.

Tips for Treating Uninsured Patients

Some facilities have found successful ways to help hospitalized patients without health insurance. Dr. Sears says that hospitalists can investigate which clinics accept uninsured patients or which local physician groups are willing to see them after discharge, in exchange for hospitalists taking care of them in the hospital. They also can investigate the community-based insurance programs that are available.

Teresa Coker, MSN, ARNP, FNP-BC, a Sound Physicians program manager at Mercy Medical Center in Cedar Rapids, Iowa, says that when patients lack insurance at her hospital, an organization will review the patient’s case, determine insurance eligibility, and assist the patient in completing the appropriate paperwork. When patients are not eligible, they are instructed to inquire about the hospital’s charity care program if they receive a bill they are unable to pay.

In addition, the community has a free health clinic that serves those without insurance. “Patients are given the address and hours prior to discharge, because it is walk-in only,” Coker says. “All patients are recommended to follow up within one week, or sooner if medications are needed.”

Dr. Englander advocates that physicians take into account medication costs, transportation, and other social considerations when planning care after hospitalization. The team at OHSU developed a low-cost formulary (based in part on widely available $4 plans from national pharmacy chains), and OHSU provides medications for uninsured patients in the program for up to 30 days following discharge.

For patients who can’t afford the $4 drug plan, case managers offer coupons for $4 prescriptions, says Malik Merchant, MD, area medical officer for the Schumachergroup in Harker Heights, Texas. He says that as many as 30% of the patients in his area are undocumented or unassigned. For more expensive medications, a social worker offers pharmaceutical company coupons when they are available. The institution also has a small budget to pay for drugs.

Dr. Merchant has found the biggest challenge to be the transition of care from inpatient to outpatient.

“Case managers and social workers prepare a financial worksheet that provides the possibility of overall cost savings for the institution, if patients are willing to participate in some upfront cost,” he says. “When our parent institution came on board, we developed contracts with local pharmacies, [a] skilled nursing facility, and PCPs to take these patients until they recovered from an acute illness. Our institution paid for these services at a reduced rate but saved money by reducing the length of their hospital stay.”

 

Dr. Feldpush says her group’s hospitals work hard to reach the uninsured. South Florida’s Memorial Healthcare System (MHS) created the Health Intervention with Targeted Services (HITS) Program, an outreach initiative that links patients with insurance programs or medical homes.³ The HITS team used a geographic information system map to target 15 neighborhoods with the highest rates of hospitalized, uninsured patients. Over a six-month period, the team approached these neighborhoods using various outreach strategies, such as health fairs, educational workshops, and door-to-door visits.³

Approximately 6,910 HITS participants have been enrolled in Medicaid, Florida’s children’s health insurance program, or an MHS community health center. Over a three-year study period, MHS saved $284,856 in the ED, about $2.8 million in inpatient costs, and roughly $4 million overall.³

Barriers to Follow-Up Care

Whether you are looking to help uninsured patients, those without a PCP, or both, the key is to try to fill in the gaps.

“As hospitalists, we need to work with pharmacists, case managers and social workers, and others to identify affordable and effective ways to provide care,” Dr. Englander says. “Interprofessional team members, community partners, and family members can help hospitalists understand patient and population health needs and available resources.”

In an effort to close transitional care gaps, OHSU developed the C-TRAIN program, a multi-component transitional care intervention that includes four main elements:

1. Transitional care nurse who sees patients in the hospital, makes home visits, and helps coordinate care 30 days post-discharge;
2. Inpatient pharmacy consultation and prescription medications at discharge from a low-cost, value-based formulary;
3. Medical home linkages, whereby OHSU partners with and provides payment to three community clinics to provide primary care for uninsured patients; and
4. Monthly implementation team meetings that convene diverse healthcare stakeholders to integrate elements of the healthcare system and engage in ongoing quality improvement.

The Schumachergroup has also found an effective solution.

“The department head of our case managers and social workers made an agreement with a local multispecialty group,” Dr. Merchant says. “The group agreed to take all discharged patients and be their PCP for 30 days, even if the patient couldn’t pay, in exchange for receiving all patients who had good insurance but did not have an established PCP.

“This has worked well. Every patient discharged from our facility has a PCP listed at discharge, and the unit clerk makes an appointment and documents it in the electronic medical record.”

Sound Physicians has set up a service line, called transitional care services, to smooth transitions of care after discharge for up to 90 days, depending on their clinical needs. It hires providers who work in post-acute facilities and who can also visit patients at home. After discharge, a nurse practitioner will visit the patient, connect him or her with a PCP, and get the patient access to care.

“Smaller hospitalist groups could set up post-discharge clinics,” Dr. Sears suggests, “so when they discharge a patient without a PCP, [the patient] could return to see one of the hospitalists there.”

Mount Carmel East Hospital, a Sound Physicians’ hospital in Columbus, Ohio, has a financial assistance program.

“The case management department provides community health resources to patients who are insured but have no PCP,” says Shelli Morris, RN. “We also have a hotline that patients can call for a list of PCPs that are accepting new patients.”

When a patient lacks insurance or a PCP, Morris is contacted by the physician or case management to provide a referral to a neighborhood health clinic. “Then, as a courtesy, we set up a post-hospital follow-up appointment,” she says.

 

By working with other care team members at facilities such as outpatient clinics and pharmacies, hospitalists and other staff have been able to improve care for patients without insurance or a PCP after discharge. Knowing the funding that is available, as well as programs to help these patients, is also integral.

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Karen Appold is a medical writer in Pennsylvania.

References

1. American Hospital Association. American Hospital Association Uncompensated Hospital Care Cost Fact Sheet. Accessed October 8, 2015.
2. The Office of the National Coordinator for Health Information Technology. Health IT in long-term and post acute care: issue brief. March 15, 2013. Accessed October 8, 2015.
3. Addison E. Gage award winner HITS the streets to connect with the uninsured. America’s Essential Hospitals. July 22, 2014. Accessed October 8, 2015.
4. DeNavas C, Proctor BD, Smith JC. Income, poverty, and health insurance coverage in the United States: 2010. United States Census Bureau. September 2011. Accessed October 8, 2015.
5. United States Census Bureau. People without health insurance coverage by selected characteristics: 2010 and 2011. Accessed October 8, 2015.
6. Coughlin TA, Holahan J, Caswell K, McGrath M. Uncompensated care for the uninsured in 2013: a detailed examination. The Henry J. Kaiser Family Foundation. May 30, 2014. Accessed October 8, 2015.

Scott Sears, MD, chief clinical officer for Sound Physicians in Tacoma, Wash., discusses why patients without health insurance put hospitalists in a difficult situation. He says hospitalists face cost pressures to discharge patients—particularly because hospitals don’t get fully reimbursed to provide care to uninsured patients and, consequently, end up subsidizing them. Meanwhile, there are incentives to meet certain quality measures, coupled with a lack of providers.

Scott Sears, MD, chief clinical officer for Sound Physicians in Tacoma, Wash., discusses why patients without health insurance put hospitalists in a difficult situation. He says hospitalists face cost pressures to discharge patients—particularly because hospitals don’t get fully reimbursed to provide care to uninsured patients and, consequently, end up subsidizing them. Meanwhile, there are incentives to meet certain quality measures, coupled with a lack of providers.

Scott Sears, MD, chief clinical officer for Sound Physicians in Tacoma, Wash., discusses why patients without health insurance put hospitalists in a difficult situation. He says hospitalists face cost pressures to discharge patients—particularly because hospitals don’t get fully reimbursed to provide care to uninsured patients and, consequently, end up subsidizing them. Meanwhile, there are incentives to meet certain quality measures, coupled with a lack of providers.

Half of U.S. physicians are experiencing some of the symptoms of burnout, with even higher rates for general internists. Implementation of the electronic health record (EHR) has been cited as the biggest driver of physician job dissatisfaction, said Christine Sinsky, MD, a former hospitalist and currently vice president of professional satisfaction at the American Medical Association (AMA), to attendees at the 19th Management of the Hospitalized Patient Conference, presented by the University of California-San Francisco.¹

Dr. Sinsky deemed physician discontent “the canary in the coal mine” for a dysfunctional healthcare system. After visiting 23 high-functioning medical teams, Dr. Sinsky said she had found that 70% to 80% of physician work output could be considered waste, defined as work that doesn’t need to be done and doesn’t add value to the patient. The AMA, she said, has made a commitment to addressing physicians’ dissatisfaction and burnout.

Dr. Sinsky offered a number of suggestions for physicians and the larger system. Among them was the idea of medical teams employing a documentation specialist, or scribe, to accompany physicians on patient rounds to help with the clerical tasks that divert physicians from patient care. She also cited David Reuben, MD, a gerontologist at UCLA whose JAMA Internal Medicine study documented his training of physician “practice partners,” often medical or nursing students, who help queue up orders in the EHR, and the improved patient satisfaction that resulted.²

“Be bold,” she advised hospitalists. “The patient care delivery modes of the future can’t be met with staffing models from the past.”

---

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Friedberg M, Chen PG, Van Busum KR, et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. 2013. Accessed November 3, 2015.
2. Reuben DB, Knudsen J, Senelick W, Glazier E, Koretz BK. The effect of a physician partner program on physician efficiency and patient satisfaction. JAMA Intern Med. 2014;174(7):1190-1193.

Half of U.S. physicians are experiencing some of the symptoms of burnout, with even higher rates for general internists. Implementation of the electronic health record (EHR) has been cited as the biggest driver of physician job dissatisfaction, said Christine Sinsky, MD, a former hospitalist and currently vice president of professional satisfaction at the American Medical Association (AMA), to attendees at the 19th Management of the Hospitalized Patient Conference, presented by the University of California-San Francisco.¹

Dr. Sinsky deemed physician discontent “the canary in the coal mine” for a dysfunctional healthcare system. After visiting 23 high-functioning medical teams, Dr. Sinsky said she had found that 70% to 80% of physician work output could be considered waste, defined as work that doesn’t need to be done and doesn’t add value to the patient. The AMA, she said, has made a commitment to addressing physicians’ dissatisfaction and burnout.

Dr. Sinsky offered a number of suggestions for physicians and the larger system. Among them was the idea of medical teams employing a documentation specialist, or scribe, to accompany physicians on patient rounds to help with the clerical tasks that divert physicians from patient care. She also cited David Reuben, MD, a gerontologist at UCLA whose JAMA Internal Medicine study documented his training of physician “practice partners,” often medical or nursing students, who help queue up orders in the EHR, and the improved patient satisfaction that resulted.²

“Be bold,” she advised hospitalists. “The patient care delivery modes of the future can’t be met with staffing models from the past.”

---

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Friedberg M, Chen PG, Van Busum KR, et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. 2013. Accessed November 3, 2015.
2. Reuben DB, Knudsen J, Senelick W, Glazier E, Koretz BK. The effect of a physician partner program on physician efficiency and patient satisfaction. JAMA Intern Med. 2014;174(7):1190-1193.

Half of U.S. physicians are experiencing some of the symptoms of burnout, with even higher rates for general internists. Implementation of the electronic health record (EHR) has been cited as the biggest driver of physician job dissatisfaction, said Christine Sinsky, MD, a former hospitalist and currently vice president of professional satisfaction at the American Medical Association (AMA), to attendees at the 19th Management of the Hospitalized Patient Conference, presented by the University of California-San Francisco.¹

Dr. Sinsky deemed physician discontent “the canary in the coal mine” for a dysfunctional healthcare system. After visiting 23 high-functioning medical teams, Dr. Sinsky said she had found that 70% to 80% of physician work output could be considered waste, defined as work that doesn’t need to be done and doesn’t add value to the patient. The AMA, she said, has made a commitment to addressing physicians’ dissatisfaction and burnout.

Dr. Sinsky offered a number of suggestions for physicians and the larger system. Among them was the idea of medical teams employing a documentation specialist, or scribe, to accompany physicians on patient rounds to help with the clerical tasks that divert physicians from patient care. She also cited David Reuben, MD, a gerontologist at UCLA whose JAMA Internal Medicine study documented his training of physician “practice partners,” often medical or nursing students, who help queue up orders in the EHR, and the improved patient satisfaction that resulted.²

“Be bold,” she advised hospitalists. “The patient care delivery modes of the future can’t be met with staffing models from the past.”

---

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Friedberg M, Chen PG, Van Busum KR, et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. 2013. Accessed November 3, 2015.
2. Reuben DB, Knudsen J, Senelick W, Glazier E, Koretz BK. The effect of a physician partner program on physician efficiency and patient satisfaction. JAMA Intern Med. 2014;174(7):1190-1193.

NEW YORK - Diagnostic codes from administrative claims data underestimate cardiovascular disease event rates, researchers report.

"Increasingly, the diagnostic codes from administrative claims data are being used to measure clinical outcomes," Dr. Bruce M. Psaty from the University of Washington, Seattle, said by email. "The methods of using only claims data as outcomes nonetheless influence the results. Methods that seek to avoid misclassification tend to underestimate event rates, and methods that attempt to include all events tend to include misclassified events such as non-event hospitalizations as part of the outcome."

Dr. Psaty's team used data from the Cardiovascular Health Study (CHS) to evaluate the degree of both misclassification and underestimation of event rates for cardiovascular disease outcomes identified solely from claims data compared with those identified through active surveillance.

An ICD9 code of 410 in the first position had a 90.6% positive predictive value (PPV) for MI, but this code only identified 53.8% of the incident MIs ascertained by active surveillance. Inclusion of this code as a secondary diagnosis identified an additional 16.6% of MI events.

Similarly, main stroke codes in the first position had an 80.4% PPV for stroke, but identified only 63.8% of the incident stroke events. For heart failure, main diagnostic codes had a high PPV of 93.2%, but identified only 27.2% of heart failure events.

Estimates of disease incidence differed markedly according to whether the incidence rates were determined by CHS surveillance, a first-position diagnostic code, or a diagnostic code in any position.

In general, misclassified events in the administrative claims data appeared to have little effect on the magnitude of associations for most cardiovascular disease risk factors, the researchers report in Circulation, online Nov. 4.

"No study is perfect, and some incomplete identification of events in a study is common," Dr. Psaty explained. "The effect depends on both the type of study and the degree of incompleteness. In a clinical trial, if there is no bias, the relative-risk comparison between the two groups remains valid even if some of the events were missed. If, on the other hand, the goal is the development of a model for the prediction of event rates to decide on whether to start a cholesterol lowering therapy, the incomplete identification of events introduces a bias in the model that is directly related to the degree of incompleteness in the identification of events."

"Events data collection should be appropriate for the study," Dr. Psaty concluded. "Published studies need to provide sufficient detail so that readers can judge whether the methods were indeed fit for purpose."

NEW YORK - Diagnostic codes from administrative claims data underestimate cardiovascular disease event rates, researchers report.

"Increasingly, the diagnostic codes from administrative claims data are being used to measure clinical outcomes," Dr. Bruce M. Psaty from the University of Washington, Seattle, said by email. "The methods of using only claims data as outcomes nonetheless influence the results. Methods that seek to avoid misclassification tend to underestimate event rates, and methods that attempt to include all events tend to include misclassified events such as non-event hospitalizations as part of the outcome."

Dr. Psaty's team used data from the Cardiovascular Health Study (CHS) to evaluate the degree of both misclassification and underestimation of event rates for cardiovascular disease outcomes identified solely from claims data compared with those identified through active surveillance.

An ICD9 code of 410 in the first position had a 90.6% positive predictive value (PPV) for MI, but this code only identified 53.8% of the incident MIs ascertained by active surveillance. Inclusion of this code as a secondary diagnosis identified an additional 16.6% of MI events.

Similarly, main stroke codes in the first position had an 80.4% PPV for stroke, but identified only 63.8% of the incident stroke events. For heart failure, main diagnostic codes had a high PPV of 93.2%, but identified only 27.2% of heart failure events.

Estimates of disease incidence differed markedly according to whether the incidence rates were determined by CHS surveillance, a first-position diagnostic code, or a diagnostic code in any position.

In general, misclassified events in the administrative claims data appeared to have little effect on the magnitude of associations for most cardiovascular disease risk factors, the researchers report in Circulation, online Nov. 4.

"No study is perfect, and some incomplete identification of events in a study is common," Dr. Psaty explained. "The effect depends on both the type of study and the degree of incompleteness. In a clinical trial, if there is no bias, the relative-risk comparison between the two groups remains valid even if some of the events were missed. If, on the other hand, the goal is the development of a model for the prediction of event rates to decide on whether to start a cholesterol lowering therapy, the incomplete identification of events introduces a bias in the model that is directly related to the degree of incompleteness in the identification of events."

"Events data collection should be appropriate for the study," Dr. Psaty concluded. "Published studies need to provide sufficient detail so that readers can judge whether the methods were indeed fit for purpose."

NEW YORK - Diagnostic codes from administrative claims data underestimate cardiovascular disease event rates, researchers report.

"Increasingly, the diagnostic codes from administrative claims data are being used to measure clinical outcomes," Dr. Bruce M. Psaty from the University of Washington, Seattle, said by email. "The methods of using only claims data as outcomes nonetheless influence the results. Methods that seek to avoid misclassification tend to underestimate event rates, and methods that attempt to include all events tend to include misclassified events such as non-event hospitalizations as part of the outcome."

Dr. Psaty's team used data from the Cardiovascular Health Study (CHS) to evaluate the degree of both misclassification and underestimation of event rates for cardiovascular disease outcomes identified solely from claims data compared with those identified through active surveillance.

An ICD9 code of 410 in the first position had a 90.6% positive predictive value (PPV) for MI, but this code only identified 53.8% of the incident MIs ascertained by active surveillance. Inclusion of this code as a secondary diagnosis identified an additional 16.6% of MI events.

Similarly, main stroke codes in the first position had an 80.4% PPV for stroke, but identified only 63.8% of the incident stroke events. For heart failure, main diagnostic codes had a high PPV of 93.2%, but identified only 27.2% of heart failure events.

Estimates of disease incidence differed markedly according to whether the incidence rates were determined by CHS surveillance, a first-position diagnostic code, or a diagnostic code in any position.

In general, misclassified events in the administrative claims data appeared to have little effect on the magnitude of associations for most cardiovascular disease risk factors, the researchers report in Circulation, online Nov. 4.

"No study is perfect, and some incomplete identification of events in a study is common," Dr. Psaty explained. "The effect depends on both the type of study and the degree of incompleteness. In a clinical trial, if there is no bias, the relative-risk comparison between the two groups remains valid even if some of the events were missed. If, on the other hand, the goal is the development of a model for the prediction of event rates to decide on whether to start a cholesterol lowering therapy, the incomplete identification of events introduces a bias in the model that is directly related to the degree of incompleteness in the identification of events."

"Events data collection should be appropriate for the study," Dr. Psaty concluded. "Published studies need to provide sufficient detail so that readers can judge whether the methods were indeed fit for purpose."