Clinical question: How helpful is the “gut feeling” that clinicians might have that a child is more ill than they look?

Background: Timely recognition of serious infections in children is difficult but critical to improved outcomes. Numerous studies have examined clinical criteria and laboratory tests to distinguish viral infections from more serious bacterial infections but have demonstrated mixed results. Clinicians’ subjective impressions of patients continue to drive many care patterns, and the relevance of a gut feeling that something is wrong remains unclear.

Study design: Prospective observational study.

Setting: Primary-care clinics in Flanders, Belgium.

Synopsis: Nearly 4,000 children 0-16 years of age were evaluated after presentation for acute illness in primary-care settings. Clinical features, overall “clinical impression” (serious illness present or absent), and “gut feelings” (present, absent or unsure) that something was wrong were prospectively recorded. Serious infections were defined as hospital admissions for potential bacterial infections.

The presence of a gut feeling significantly increased the risk of serious illness (likelihood ratio 25.5, 95% confidence interval 7.9 to 82.0) and had a consistently higher specificity than clinical impression alone. The overall sensitivity of the gut feeling in this cohort was 61.9% with a specificity of 97.2%, while the positive predictive value was 10.8% and negative predictive value 99.8%. A history of convulsions and parental concerns were independently strongly associated with a positive gut feeling.

Similar to other clinical and laboratory evaluations designed to detect serious illness, the absence of a gut feeling might be the more useful finding from this study. Limitations of the data include an inability to further delve into what gives rise to a gut feeling in clinical practice as well as a moderate level of variance in the multivariate models. Additionally, only 21 children were ultimately admitted to the hospital, which, in conjunction with the subsequent power limitations, highlights the proverbial difficulty of finding that “needle in the haystack.”

Bottom line: The presence or absence of a gut feeling that something is wrong might be an important component of the history in acute childhood illness.

Citation: Van den Bruel A, Thompson M, Buntinx F, Mant D. Clinicians’ gut feeling about serious infections in children: observational study. BMJ. 2012;345:e6144.

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

Clinical question: How helpful is the “gut feeling” that clinicians might have that a child is more ill than they look?

Background: Timely recognition of serious infections in children is difficult but critical to improved outcomes. Numerous studies have examined clinical criteria and laboratory tests to distinguish viral infections from more serious bacterial infections but have demonstrated mixed results. Clinicians’ subjective impressions of patients continue to drive many care patterns, and the relevance of a gut feeling that something is wrong remains unclear.

Study design: Prospective observational study.

Setting: Primary-care clinics in Flanders, Belgium.

Synopsis: Nearly 4,000 children 0-16 years of age were evaluated after presentation for acute illness in primary-care settings. Clinical features, overall “clinical impression” (serious illness present or absent), and “gut feelings” (present, absent or unsure) that something was wrong were prospectively recorded. Serious infections were defined as hospital admissions for potential bacterial infections.

The presence of a gut feeling significantly increased the risk of serious illness (likelihood ratio 25.5, 95% confidence interval 7.9 to 82.0) and had a consistently higher specificity than clinical impression alone. The overall sensitivity of the gut feeling in this cohort was 61.9% with a specificity of 97.2%, while the positive predictive value was 10.8% and negative predictive value 99.8%. A history of convulsions and parental concerns were independently strongly associated with a positive gut feeling.

Similar to other clinical and laboratory evaluations designed to detect serious illness, the absence of a gut feeling might be the more useful finding from this study. Limitations of the data include an inability to further delve into what gives rise to a gut feeling in clinical practice as well as a moderate level of variance in the multivariate models. Additionally, only 21 children were ultimately admitted to the hospital, which, in conjunction with the subsequent power limitations, highlights the proverbial difficulty of finding that “needle in the haystack.”

Bottom line: The presence or absence of a gut feeling that something is wrong might be an important component of the history in acute childhood illness.

Citation: Van den Bruel A, Thompson M, Buntinx F, Mant D. Clinicians’ gut feeling about serious infections in children: observational study. BMJ. 2012;345:e6144.

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

Clinical question: How helpful is the “gut feeling” that clinicians might have that a child is more ill than they look?

Background: Timely recognition of serious infections in children is difficult but critical to improved outcomes. Numerous studies have examined clinical criteria and laboratory tests to distinguish viral infections from more serious bacterial infections but have demonstrated mixed results. Clinicians’ subjective impressions of patients continue to drive many care patterns, and the relevance of a gut feeling that something is wrong remains unclear.

Study design: Prospective observational study.

Setting: Primary-care clinics in Flanders, Belgium.

Synopsis: Nearly 4,000 children 0-16 years of age were evaluated after presentation for acute illness in primary-care settings. Clinical features, overall “clinical impression” (serious illness present or absent), and “gut feelings” (present, absent or unsure) that something was wrong were prospectively recorded. Serious infections were defined as hospital admissions for potential bacterial infections.

The presence of a gut feeling significantly increased the risk of serious illness (likelihood ratio 25.5, 95% confidence interval 7.9 to 82.0) and had a consistently higher specificity than clinical impression alone. The overall sensitivity of the gut feeling in this cohort was 61.9% with a specificity of 97.2%, while the positive predictive value was 10.8% and negative predictive value 99.8%. A history of convulsions and parental concerns were independently strongly associated with a positive gut feeling.

Similar to other clinical and laboratory evaluations designed to detect serious illness, the absence of a gut feeling might be the more useful finding from this study. Limitations of the data include an inability to further delve into what gives rise to a gut feeling in clinical practice as well as a moderate level of variance in the multivariate models. Additionally, only 21 children were ultimately admitted to the hospital, which, in conjunction with the subsequent power limitations, highlights the proverbial difficulty of finding that “needle in the haystack.”

Bottom line: The presence or absence of a gut feeling that something is wrong might be an important component of the history in acute childhood illness.

Citation: Van den Bruel A, Thompson M, Buntinx F, Mant D. Clinicians’ gut feeling about serious infections in children: observational study. BMJ. 2012;345:e6144.

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

Case

A generally healthy, 74-year-old man presents with sudden-onset abdominal pain due to acute pancreatitis. Computed tomography (CT) of his abdomen shows pancreatic inflammation and an incidental finding of a 4.5-cm abdominal aortic aneurysm. He had never had any imaging of his abdomen prior to this study and described no prior episodes of abdominal pain.

When should his abdominal aortic aneurysm be treated?

Overview

An abdominal aortic aneurysm (AAA) is an abnormal dilation of the abdominal aorta between the diaphragm and the aortic bifurcation of the iliac arteries. An AAA is usually defined as a dilatation with a diameter of >3 cm or 50% greater than the typical diameter. Most AAAs are located in the infrarenal aorta, proximal to the iliac bifurcation.

Population screening programs show a prevalence of AAA of 4% to 8% in men aged 65 to 80 years.¹ AAA prevalence is approximately six times greater in men than women, though the prevalence in women might be increasing.¹ AAA is most common in white men, with black men and those of Asian heritage having lower risk. A combination of genetic predisposition and environmental and physiologic factors lead to initiation and progression of AAAs; family history, male sex, advanced age, and history of smoking are major risk factors.

Mortality after AAA rupture is high. Approximately 62% of patients die prior to hospital arrival.² Of those who undergo emergent AAA surgery, 50% will die.¹

Aortic repair with a prosthetic vascular graft reduces morbidity and mortality from rupture, but the risks of repair are not trivial.²

Review of the Data

Risk of rupture. An AAA should be repaired when the risk of rupture outweighs the risks of surgical repair. Symptomatic aneurysms—such as those causing back or abdominal pain—have a higher risk of rupture than asymptomatic aneurysms. Most AAAs are asymptomatic and, in the absence of imaging, not identified until the time of rupture. Given the significant mortality associated with rupture, there is benefit to intervening on asymptomatic aneurysms before rupture.

The risk of AAA rupture has been studied in patients who either have been unfit for surgical repair or uninterested in intervention. Risk of rupture increases substantially with aneurysm size. Lederle et al estimated a two-year aneurysm rupture risk of 22.1% for AAA with a diameter of 5.0 to 5.9 cm, 18.9% for 6.0 to 6.9 cm, and 43.4% for a diameter ≥7.0 cm.³ In another study of 476 patients, the average risks of rupture in male and female patients with an AAA of 5.0 to 5.9 cm were 1.0% and 3.9% per year, respectively. For male and female patients with ≥6.0 cm AAAs, risks of rupture were 14.1% and 22.3% per year.⁴ Women with AAA have been found to have a higher risk of rupture in all studies in which female patients were included.

Because rupture risk increases with size, predicting the rate of growth is clinically important. Powell et al conducted a systematic review of growth rates of small AAAs.⁵ In 15 studies that examined 7,630 patients, the growth rate for a 3.5-cm aneurysm was estimated at 1.9 mm/year and for a 4.5-cm aneurysm was 3.5 mm/year. Given an exponentially increasing aneurysm diameter, this suggests an elapsed time of 6.2 years for a 3.5-cm aneurysm to grow to 5.5 cm, and 2.3 years for a 4.5-cm AAA to grow to 5.5 cm. This prediction does not account for individual variability in growth rate. Some AAAs grow quickly, others erratically, and others not at all. This growth variability is influenced by individual characteristics including cigarette smoking, sex, age, and other factors.

Medical prevention of progression and rupture. Studies have assessed whether modification of risk factors can delay progression of growth of AAAs. In a small aneurysm trial in the United Kingdom, self-reported smoking status was associated with an incrementally increased growth rate of 0.4 mm per year.⁵ Each year of smoking increases the relative risk of AAA by 4%, and continued smoking leads to more rapid AAA expansion.6 There is no clear relationship between cholesterol levels and AAA expansion rate. Observational studies suggest that aneurysm expansion decreases with statin use, but there is not sufficient evidence to recommend statin therapy for AAA alone.⁶

Many patients with AAA, however, are candidates for statins because of concomitant coronary artery or peripheral vascular disease. Small, randomized controlled trials have shown that macrolides and tetracycline antibiotics might inhibit AAA growth, but prescribing them for this purpose is not currently the standard of care.⁷ Elevated mean blood pressure has been associated with rupture, but there is not good evidence showing delay of progression with treatment of hypertension.⁶ Early observational studies suggested that beta-blocker use would decrease AAA progression, but further evidence has not supported their benefit in slowing progression of size.⁸ Likewise, use of angiotensin-converting enzyme inhibitors has also shown no growth inhibition.⁷ An ongoing Cochrane review is evaluating evidence for these medical treatments of AAA.⁹

Surgical prevention of rupture. There are two surgical methods of AAA repair: open repair and endovascular aneurysm repair (EVAR). Both involve use of a prosthetic graft to prevent the aneurysm from enlarging. The EVAR procedure typically involves entry at the femoral artery, with use of catheters and guide wires to advance a graft to the desired location and anchor it in place. Because this utilizes an endovascular approach, regional rather than general anesthesia can be used.

Multiple investigators have evaluated for differences in outcomes between the two methods of surgical AAA repair. Studies have shown increased 30-day postoperative mortality with open repair, as well as significantly higher rates of postoperative cardiac, pulmonary, and renal complications. One randomized controlled study found 30-day operative mortality of 1.8% in the EVAR group and 4.3% in the open repair group.¹⁰ However, after a median six-year follow-up of patients after EVAR or open repair, there is no difference in total mortality or aneurysm-related mortality.¹⁰ Compared with open repair, the need for long-term surveillance and re-intervention post-EVAR is higher, with endoleak and graft migration the most common complications. This accounts for the loss of early survival advantage in post-EVAR patients. By two years post-operation, complication after repair with either technique is not statistically different. De Bruin et al found that six years after randomization for repair type, cumulative survival rates were 69.9% for patients after open repair and 68.9% with EVAR.¹¹

Studies also have focused on subgroups of patients with a higher operative risk and shorter life expectancy, such as the elderly.¹² A pooled analysis of 13,419 patients aged ≥80 years from six observational studies showed 8.6% immediate mortality after open repair and 2.3% after EVAR (risk difference 6.2%, 95% CI 5.4-7.0%).¹³ Pooled analysis of three longer-term studies showed similar overall survival at three years after EVAR and open repair.¹³ When EVAR is not available, open repair has acceptable short- and long-term survival in patients aged ≥80 years with an AAA at high risk of rupture.¹⁴

Screening. A Cochrane review evaluated the effect of ultrasound screening of asymptomatic AAA on mortality. In 127,891 men and 9,342 women aged 65 to 79, researchers found a significant decrease in mortality in men aged 65 to 79 who were screened (odds ratio 0.6, 95% CI 0.47-0.78) but no benefit to screening of women.15 The current U.S. Preventive Services Task Force (USPSTF) guidelines recommend one-time ultrasound-guided (USG) screening for AAA in men aged 65 to 75 who have any history of tobacco use. For men in this age group who have never smoked, the balance between benefits and harms of screening is too close for the USPSTF to make recommendations. Because of the lower prevalence in women, the USPSTF recommends against screening women for AAA.¹⁸

Timing of repair. Early repair of small AAAs (4 cm to 5.5 cm) has no long-term survival benefit compared to ultrasound surveillance without repair.^16,17 Therefore, AAAs <5.5 cm should be followed with regular ultrasound surveillance every six months, with referral to surgery if the diameter reaches 5.5 cm, or grows >1 cm a year. The size at which surgery should be performed might be lower in women, given that their risk of rupture is higher than men. A thoughtful discussion of individual risks should take place in every case, but in many patients, even the elderly, repair of a large asymptomatic AAA is indicated. ⁵

Back to the Case

Our patient should have repeat imaging of his AAA in six months and regular surveillance afterward to monitor for growth every six months. When the AAA is >5.5 cm or if it grows >1 cm a year, he should be evaluated for EVAR or open repair.

Bottom Line

The current USPSTF guidelines recommend one-time ultrasound-guided (USG) screening for AAA in men aged 65 to 75 with a history of smoking. If an AAA >3 cm is found, the patient should undergo regular USG screening every six months. The AAA should be repaired if >5.5 cm or symptomatic, via either an endoscopic or open approach.

Dr. Best is a hospitalist at University of Washington Medicine at Harborview and associate program director of the internal-medicine residency program at the University of Washington, Seattle. Dr. Carpenter is a fellow in the division of geriatrics at the University of California at San Franscisco.

References

1. Nordon IM, Hinchliffe RJ, Loftus IM, Thompson MM. Pathophysiology and epidemiology of abdominal aortic aneurysms. Nat Rev Cardiol. 2011;8, 92-102.
2. Ernst CB. Abdominal aortic aneurysm. N Engl J Med. 1993;328(16):1167-1172.
3. Lederle FA, Johnson GR, Wilson SE, et al. Rupture rate of large abdominal aortic aneurysms in patients refusing or unfit for elective repair. JAMA. 2002;287:2968-2972
4. Brown PM, Zelt DT, Sobolev B. The risk of rupture in untreated aneurysms: the impact of size, gender, and expansion rate. J Vasc Surg. 2003;37:280-284.
5. Powell JT, Sweeting MJ, Brown LC, Gotensparre SM, Fowkes FG, Thompson SG. Systematic review and meta-analysis of growth rates of small abdominal aortic aneurysms. British Journal of Surgery. 2011;98:609-618.
6. Brown LC, Powell JT. Risk factors for aneurysm rupture in patients kept under ultrasound surveillance. UK Small Aneurysm Trial Participants. Ann Surg. 1999;230(3):289-297.
7. Baxter BT, Terrin MC, Dalman RL. Medical management of small abdominal aortic aneurysms. Circulation. 2008;117:1883-1889.
8. The Propranolol Aneurysm Trial Investigators. Propranolol for small abdominal aortic aneurysms: results of a randomized trial. J Vasc Surg. 2002:35:72-79.
9. Ruhani G, Robertson L, Clarke M. Medical treatment for small abdominal aortic aneurysms. Cochrane Database for Systematic Reviews 2012. Sep 12;9:CD009536. doi: 10.1002/14651858.
10. The United Kingdom EVAR Trial Investigators. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med. 2010; 362:1863-1871.
11. De Bruin JL, Baas AF, Buth J, et al. Long-term outcome of open or endovascular repair of abdominal aortic aneurysm. N Engl J Med. 2010;362:1881-1889.
12. Jackson RS, Chang DC, Freischlag JA. Comparison of long-term survival after open vs. endovascular repair of intact abdominal aortic aneurysm among Medicare beneficiaries. JAMA. 2012;307(15):1621-1628.
13. Biancari F, Catania A, D’Andrea V. Elective endovascular vs. open repair of abdominal aortic aneurysm in patients aged 80 years and older: systematic review and meta-analysis. Eur J Vasc Endovasc Surg. 2011;42:571-576.
14. Schermerhorn ML, O’Malley AJ, Jhaveri A, Cotterill P, Pomposelli F, Landon BE. Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population. N Engl J Med. 2008;358:464-474.
15. Cosford PA, Leng GC, Tomas J. Screening for abdominal aortic aneurysm. Cochrane Database for Systematic Reviews 2007, Issue 2. Art. No.: CD002945. DOI: 10.1002/14651858.CD002945.pub2.
16. Filardo G, Powell JT, Martinez MA, Ballard DJ. Surgery for small asymptomatic abdominal aortic aneurysms. Cochrane Database for Systematic Reviews 2012, Issue 3. Art. No.:CD001835. DOI: 10.1002/14651858.CD001835.pub3.
17. The UK Small Aneurysm Trial Participants. Final 12-year follow-up of surgery versus surveillance in the UK small aneurysm trial. Brit J Surg. 2007;94:702-708.
18. U.S. Preventive Services Task Force. Screening for Abdominal Aortic Aneurysm: Recommendation Statement. AHRQ Publication No. 05-0569-A, February 2005.

Case

A generally healthy, 74-year-old man presents with sudden-onset abdominal pain due to acute pancreatitis. Computed tomography (CT) of his abdomen shows pancreatic inflammation and an incidental finding of a 4.5-cm abdominal aortic aneurysm. He had never had any imaging of his abdomen prior to this study and described no prior episodes of abdominal pain.

When should his abdominal aortic aneurysm be treated?

Overview

An abdominal aortic aneurysm (AAA) is an abnormal dilation of the abdominal aorta between the diaphragm and the aortic bifurcation of the iliac arteries. An AAA is usually defined as a dilatation with a diameter of >3 cm or 50% greater than the typical diameter. Most AAAs are located in the infrarenal aorta, proximal to the iliac bifurcation.

Population screening programs show a prevalence of AAA of 4% to 8% in men aged 65 to 80 years.¹ AAA prevalence is approximately six times greater in men than women, though the prevalence in women might be increasing.¹ AAA is most common in white men, with black men and those of Asian heritage having lower risk. A combination of genetic predisposition and environmental and physiologic factors lead to initiation and progression of AAAs; family history, male sex, advanced age, and history of smoking are major risk factors.

Mortality after AAA rupture is high. Approximately 62% of patients die prior to hospital arrival.² Of those who undergo emergent AAA surgery, 50% will die.¹

Aortic repair with a prosthetic vascular graft reduces morbidity and mortality from rupture, but the risks of repair are not trivial.²

Review of the Data

Risk of rupture. An AAA should be repaired when the risk of rupture outweighs the risks of surgical repair. Symptomatic aneurysms—such as those causing back or abdominal pain—have a higher risk of rupture than asymptomatic aneurysms. Most AAAs are asymptomatic and, in the absence of imaging, not identified until the time of rupture. Given the significant mortality associated with rupture, there is benefit to intervening on asymptomatic aneurysms before rupture.

The risk of AAA rupture has been studied in patients who either have been unfit for surgical repair or uninterested in intervention. Risk of rupture increases substantially with aneurysm size. Lederle et al estimated a two-year aneurysm rupture risk of 22.1% for AAA with a diameter of 5.0 to 5.9 cm, 18.9% for 6.0 to 6.9 cm, and 43.4% for a diameter ≥7.0 cm.³ In another study of 476 patients, the average risks of rupture in male and female patients with an AAA of 5.0 to 5.9 cm were 1.0% and 3.9% per year, respectively. For male and female patients with ≥6.0 cm AAAs, risks of rupture were 14.1% and 22.3% per year.⁴ Women with AAA have been found to have a higher risk of rupture in all studies in which female patients were included.

Because rupture risk increases with size, predicting the rate of growth is clinically important. Powell et al conducted a systematic review of growth rates of small AAAs.⁵ In 15 studies that examined 7,630 patients, the growth rate for a 3.5-cm aneurysm was estimated at 1.9 mm/year and for a 4.5-cm aneurysm was 3.5 mm/year. Given an exponentially increasing aneurysm diameter, this suggests an elapsed time of 6.2 years for a 3.5-cm aneurysm to grow to 5.5 cm, and 2.3 years for a 4.5-cm AAA to grow to 5.5 cm. This prediction does not account for individual variability in growth rate. Some AAAs grow quickly, others erratically, and others not at all. This growth variability is influenced by individual characteristics including cigarette smoking, sex, age, and other factors.

Medical prevention of progression and rupture. Studies have assessed whether modification of risk factors can delay progression of growth of AAAs. In a small aneurysm trial in the United Kingdom, self-reported smoking status was associated with an incrementally increased growth rate of 0.4 mm per year.⁵ Each year of smoking increases the relative risk of AAA by 4%, and continued smoking leads to more rapid AAA expansion.6 There is no clear relationship between cholesterol levels and AAA expansion rate. Observational studies suggest that aneurysm expansion decreases with statin use, but there is not sufficient evidence to recommend statin therapy for AAA alone.⁶

Many patients with AAA, however, are candidates for statins because of concomitant coronary artery or peripheral vascular disease. Small, randomized controlled trials have shown that macrolides and tetracycline antibiotics might inhibit AAA growth, but prescribing them for this purpose is not currently the standard of care.⁷ Elevated mean blood pressure has been associated with rupture, but there is not good evidence showing delay of progression with treatment of hypertension.⁶ Early observational studies suggested that beta-blocker use would decrease AAA progression, but further evidence has not supported their benefit in slowing progression of size.⁸ Likewise, use of angiotensin-converting enzyme inhibitors has also shown no growth inhibition.⁷ An ongoing Cochrane review is evaluating evidence for these medical treatments of AAA.⁹

Surgical prevention of rupture. There are two surgical methods of AAA repair: open repair and endovascular aneurysm repair (EVAR). Both involve use of a prosthetic graft to prevent the aneurysm from enlarging. The EVAR procedure typically involves entry at the femoral artery, with use of catheters and guide wires to advance a graft to the desired location and anchor it in place. Because this utilizes an endovascular approach, regional rather than general anesthesia can be used.

Multiple investigators have evaluated for differences in outcomes between the two methods of surgical AAA repair. Studies have shown increased 30-day postoperative mortality with open repair, as well as significantly higher rates of postoperative cardiac, pulmonary, and renal complications. One randomized controlled study found 30-day operative mortality of 1.8% in the EVAR group and 4.3% in the open repair group.¹⁰ However, after a median six-year follow-up of patients after EVAR or open repair, there is no difference in total mortality or aneurysm-related mortality.¹⁰ Compared with open repair, the need for long-term surveillance and re-intervention post-EVAR is higher, with endoleak and graft migration the most common complications. This accounts for the loss of early survival advantage in post-EVAR patients. By two years post-operation, complication after repair with either technique is not statistically different. De Bruin et al found that six years after randomization for repair type, cumulative survival rates were 69.9% for patients after open repair and 68.9% with EVAR.¹¹

Studies also have focused on subgroups of patients with a higher operative risk and shorter life expectancy, such as the elderly.¹² A pooled analysis of 13,419 patients aged ≥80 years from six observational studies showed 8.6% immediate mortality after open repair and 2.3% after EVAR (risk difference 6.2%, 95% CI 5.4-7.0%).¹³ Pooled analysis of three longer-term studies showed similar overall survival at three years after EVAR and open repair.¹³ When EVAR is not available, open repair has acceptable short- and long-term survival in patients aged ≥80 years with an AAA at high risk of rupture.¹⁴

Screening. A Cochrane review evaluated the effect of ultrasound screening of asymptomatic AAA on mortality. In 127,891 men and 9,342 women aged 65 to 79, researchers found a significant decrease in mortality in men aged 65 to 79 who were screened (odds ratio 0.6, 95% CI 0.47-0.78) but no benefit to screening of women.15 The current U.S. Preventive Services Task Force (USPSTF) guidelines recommend one-time ultrasound-guided (USG) screening for AAA in men aged 65 to 75 who have any history of tobacco use. For men in this age group who have never smoked, the balance between benefits and harms of screening is too close for the USPSTF to make recommendations. Because of the lower prevalence in women, the USPSTF recommends against screening women for AAA.¹⁸

Timing of repair. Early repair of small AAAs (4 cm to 5.5 cm) has no long-term survival benefit compared to ultrasound surveillance without repair.^16,17 Therefore, AAAs <5.5 cm should be followed with regular ultrasound surveillance every six months, with referral to surgery if the diameter reaches 5.5 cm, or grows >1 cm a year. The size at which surgery should be performed might be lower in women, given that their risk of rupture is higher than men. A thoughtful discussion of individual risks should take place in every case, but in many patients, even the elderly, repair of a large asymptomatic AAA is indicated. ⁵

Back to the Case

Our patient should have repeat imaging of his AAA in six months and regular surveillance afterward to monitor for growth every six months. When the AAA is >5.5 cm or if it grows >1 cm a year, he should be evaluated for EVAR or open repair.

Bottom Line

The current USPSTF guidelines recommend one-time ultrasound-guided (USG) screening for AAA in men aged 65 to 75 with a history of smoking. If an AAA >3 cm is found, the patient should undergo regular USG screening every six months. The AAA should be repaired if >5.5 cm or symptomatic, via either an endoscopic or open approach.

Dr. Best is a hospitalist at University of Washington Medicine at Harborview and associate program director of the internal-medicine residency program at the University of Washington, Seattle. Dr. Carpenter is a fellow in the division of geriatrics at the University of California at San Franscisco.

References

1. Nordon IM, Hinchliffe RJ, Loftus IM, Thompson MM. Pathophysiology and epidemiology of abdominal aortic aneurysms. Nat Rev Cardiol. 2011;8, 92-102.
2. Ernst CB. Abdominal aortic aneurysm. N Engl J Med. 1993;328(16):1167-1172.
3. Lederle FA, Johnson GR, Wilson SE, et al. Rupture rate of large abdominal aortic aneurysms in patients refusing or unfit for elective repair. JAMA. 2002;287:2968-2972
4. Brown PM, Zelt DT, Sobolev B. The risk of rupture in untreated aneurysms: the impact of size, gender, and expansion rate. J Vasc Surg. 2003;37:280-284.
5. Powell JT, Sweeting MJ, Brown LC, Gotensparre SM, Fowkes FG, Thompson SG. Systematic review and meta-analysis of growth rates of small abdominal aortic aneurysms. British Journal of Surgery. 2011;98:609-618.
6. Brown LC, Powell JT. Risk factors for aneurysm rupture in patients kept under ultrasound surveillance. UK Small Aneurysm Trial Participants. Ann Surg. 1999;230(3):289-297.
7. Baxter BT, Terrin MC, Dalman RL. Medical management of small abdominal aortic aneurysms. Circulation. 2008;117:1883-1889.
8. The Propranolol Aneurysm Trial Investigators. Propranolol for small abdominal aortic aneurysms: results of a randomized trial. J Vasc Surg. 2002:35:72-79.
9. Ruhani G, Robertson L, Clarke M. Medical treatment for small abdominal aortic aneurysms. Cochrane Database for Systematic Reviews 2012. Sep 12;9:CD009536. doi: 10.1002/14651858.
10. The United Kingdom EVAR Trial Investigators. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med. 2010; 362:1863-1871.
11. De Bruin JL, Baas AF, Buth J, et al. Long-term outcome of open or endovascular repair of abdominal aortic aneurysm. N Engl J Med. 2010;362:1881-1889.
12. Jackson RS, Chang DC, Freischlag JA. Comparison of long-term survival after open vs. endovascular repair of intact abdominal aortic aneurysm among Medicare beneficiaries. JAMA. 2012;307(15):1621-1628.
13. Biancari F, Catania A, D’Andrea V. Elective endovascular vs. open repair of abdominal aortic aneurysm in patients aged 80 years and older: systematic review and meta-analysis. Eur J Vasc Endovasc Surg. 2011;42:571-576.
14. Schermerhorn ML, O’Malley AJ, Jhaveri A, Cotterill P, Pomposelli F, Landon BE. Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population. N Engl J Med. 2008;358:464-474.
15. Cosford PA, Leng GC, Tomas J. Screening for abdominal aortic aneurysm. Cochrane Database for Systematic Reviews 2007, Issue 2. Art. No.: CD002945. DOI: 10.1002/14651858.CD002945.pub2.
16. Filardo G, Powell JT, Martinez MA, Ballard DJ. Surgery for small asymptomatic abdominal aortic aneurysms. Cochrane Database for Systematic Reviews 2012, Issue 3. Art. No.:CD001835. DOI: 10.1002/14651858.CD001835.pub3.
17. The UK Small Aneurysm Trial Participants. Final 12-year follow-up of surgery versus surveillance in the UK small aneurysm trial. Brit J Surg. 2007;94:702-708.
18. U.S. Preventive Services Task Force. Screening for Abdominal Aortic Aneurysm: Recommendation Statement. AHRQ Publication No. 05-0569-A, February 2005.

Case

A generally healthy, 74-year-old man presents with sudden-onset abdominal pain due to acute pancreatitis. Computed tomography (CT) of his abdomen shows pancreatic inflammation and an incidental finding of a 4.5-cm abdominal aortic aneurysm. He had never had any imaging of his abdomen prior to this study and described no prior episodes of abdominal pain.

When should his abdominal aortic aneurysm be treated?

Overview

An abdominal aortic aneurysm (AAA) is an abnormal dilation of the abdominal aorta between the diaphragm and the aortic bifurcation of the iliac arteries. An AAA is usually defined as a dilatation with a diameter of >3 cm or 50% greater than the typical diameter. Most AAAs are located in the infrarenal aorta, proximal to the iliac bifurcation.

Population screening programs show a prevalence of AAA of 4% to 8% in men aged 65 to 80 years.¹ AAA prevalence is approximately six times greater in men than women, though the prevalence in women might be increasing.¹ AAA is most common in white men, with black men and those of Asian heritage having lower risk. A combination of genetic predisposition and environmental and physiologic factors lead to initiation and progression of AAAs; family history, male sex, advanced age, and history of smoking are major risk factors.

Mortality after AAA rupture is high. Approximately 62% of patients die prior to hospital arrival.² Of those who undergo emergent AAA surgery, 50% will die.¹

Aortic repair with a prosthetic vascular graft reduces morbidity and mortality from rupture, but the risks of repair are not trivial.²

Review of the Data

Risk of rupture. An AAA should be repaired when the risk of rupture outweighs the risks of surgical repair. Symptomatic aneurysms—such as those causing back or abdominal pain—have a higher risk of rupture than asymptomatic aneurysms. Most AAAs are asymptomatic and, in the absence of imaging, not identified until the time of rupture. Given the significant mortality associated with rupture, there is benefit to intervening on asymptomatic aneurysms before rupture.

The risk of AAA rupture has been studied in patients who either have been unfit for surgical repair or uninterested in intervention. Risk of rupture increases substantially with aneurysm size. Lederle et al estimated a two-year aneurysm rupture risk of 22.1% for AAA with a diameter of 5.0 to 5.9 cm, 18.9% for 6.0 to 6.9 cm, and 43.4% for a diameter ≥7.0 cm.³ In another study of 476 patients, the average risks of rupture in male and female patients with an AAA of 5.0 to 5.9 cm were 1.0% and 3.9% per year, respectively. For male and female patients with ≥6.0 cm AAAs, risks of rupture were 14.1% and 22.3% per year.⁴ Women with AAA have been found to have a higher risk of rupture in all studies in which female patients were included.

Because rupture risk increases with size, predicting the rate of growth is clinically important. Powell et al conducted a systematic review of growth rates of small AAAs.⁵ In 15 studies that examined 7,630 patients, the growth rate for a 3.5-cm aneurysm was estimated at 1.9 mm/year and for a 4.5-cm aneurysm was 3.5 mm/year. Given an exponentially increasing aneurysm diameter, this suggests an elapsed time of 6.2 years for a 3.5-cm aneurysm to grow to 5.5 cm, and 2.3 years for a 4.5-cm AAA to grow to 5.5 cm. This prediction does not account for individual variability in growth rate. Some AAAs grow quickly, others erratically, and others not at all. This growth variability is influenced by individual characteristics including cigarette smoking, sex, age, and other factors.

Medical prevention of progression and rupture. Studies have assessed whether modification of risk factors can delay progression of growth of AAAs. In a small aneurysm trial in the United Kingdom, self-reported smoking status was associated with an incrementally increased growth rate of 0.4 mm per year.⁵ Each year of smoking increases the relative risk of AAA by 4%, and continued smoking leads to more rapid AAA expansion.6 There is no clear relationship between cholesterol levels and AAA expansion rate. Observational studies suggest that aneurysm expansion decreases with statin use, but there is not sufficient evidence to recommend statin therapy for AAA alone.⁶

Many patients with AAA, however, are candidates for statins because of concomitant coronary artery or peripheral vascular disease. Small, randomized controlled trials have shown that macrolides and tetracycline antibiotics might inhibit AAA growth, but prescribing them for this purpose is not currently the standard of care.⁷ Elevated mean blood pressure has been associated with rupture, but there is not good evidence showing delay of progression with treatment of hypertension.⁶ Early observational studies suggested that beta-blocker use would decrease AAA progression, but further evidence has not supported their benefit in slowing progression of size.⁸ Likewise, use of angiotensin-converting enzyme inhibitors has also shown no growth inhibition.⁷ An ongoing Cochrane review is evaluating evidence for these medical treatments of AAA.⁹

Surgical prevention of rupture. There are two surgical methods of AAA repair: open repair and endovascular aneurysm repair (EVAR). Both involve use of a prosthetic graft to prevent the aneurysm from enlarging. The EVAR procedure typically involves entry at the femoral artery, with use of catheters and guide wires to advance a graft to the desired location and anchor it in place. Because this utilizes an endovascular approach, regional rather than general anesthesia can be used.

Multiple investigators have evaluated for differences in outcomes between the two methods of surgical AAA repair. Studies have shown increased 30-day postoperative mortality with open repair, as well as significantly higher rates of postoperative cardiac, pulmonary, and renal complications. One randomized controlled study found 30-day operative mortality of 1.8% in the EVAR group and 4.3% in the open repair group.¹⁰ However, after a median six-year follow-up of patients after EVAR or open repair, there is no difference in total mortality or aneurysm-related mortality.¹⁰ Compared with open repair, the need for long-term surveillance and re-intervention post-EVAR is higher, with endoleak and graft migration the most common complications. This accounts for the loss of early survival advantage in post-EVAR patients. By two years post-operation, complication after repair with either technique is not statistically different. De Bruin et al found that six years after randomization for repair type, cumulative survival rates were 69.9% for patients after open repair and 68.9% with EVAR.¹¹

Studies also have focused on subgroups of patients with a higher operative risk and shorter life expectancy, such as the elderly.¹² A pooled analysis of 13,419 patients aged ≥80 years from six observational studies showed 8.6% immediate mortality after open repair and 2.3% after EVAR (risk difference 6.2%, 95% CI 5.4-7.0%).¹³ Pooled analysis of three longer-term studies showed similar overall survival at three years after EVAR and open repair.¹³ When EVAR is not available, open repair has acceptable short- and long-term survival in patients aged ≥80 years with an AAA at high risk of rupture.¹⁴

Screening. A Cochrane review evaluated the effect of ultrasound screening of asymptomatic AAA on mortality. In 127,891 men and 9,342 women aged 65 to 79, researchers found a significant decrease in mortality in men aged 65 to 79 who were screened (odds ratio 0.6, 95% CI 0.47-0.78) but no benefit to screening of women.15 The current U.S. Preventive Services Task Force (USPSTF) guidelines recommend one-time ultrasound-guided (USG) screening for AAA in men aged 65 to 75 who have any history of tobacco use. For men in this age group who have never smoked, the balance between benefits and harms of screening is too close for the USPSTF to make recommendations. Because of the lower prevalence in women, the USPSTF recommends against screening women for AAA.¹⁸

Timing of repair. Early repair of small AAAs (4 cm to 5.5 cm) has no long-term survival benefit compared to ultrasound surveillance without repair.^16,17 Therefore, AAAs <5.5 cm should be followed with regular ultrasound surveillance every six months, with referral to surgery if the diameter reaches 5.5 cm, or grows >1 cm a year. The size at which surgery should be performed might be lower in women, given that their risk of rupture is higher than men. A thoughtful discussion of individual risks should take place in every case, but in many patients, even the elderly, repair of a large asymptomatic AAA is indicated. ⁵

Back to the Case

Our patient should have repeat imaging of his AAA in six months and regular surveillance afterward to monitor for growth every six months. When the AAA is >5.5 cm or if it grows >1 cm a year, he should be evaluated for EVAR or open repair.

Bottom Line

The current USPSTF guidelines recommend one-time ultrasound-guided (USG) screening for AAA in men aged 65 to 75 with a history of smoking. If an AAA >3 cm is found, the patient should undergo regular USG screening every six months. The AAA should be repaired if >5.5 cm or symptomatic, via either an endoscopic or open approach.

Dr. Best is a hospitalist at University of Washington Medicine at Harborview and associate program director of the internal-medicine residency program at the University of Washington, Seattle. Dr. Carpenter is a fellow in the division of geriatrics at the University of California at San Franscisco.

References

1. Nordon IM, Hinchliffe RJ, Loftus IM, Thompson MM. Pathophysiology and epidemiology of abdominal aortic aneurysms. Nat Rev Cardiol. 2011;8, 92-102.
2. Ernst CB. Abdominal aortic aneurysm. N Engl J Med. 1993;328(16):1167-1172.
3. Lederle FA, Johnson GR, Wilson SE, et al. Rupture rate of large abdominal aortic aneurysms in patients refusing or unfit for elective repair. JAMA. 2002;287:2968-2972
4. Brown PM, Zelt DT, Sobolev B. The risk of rupture in untreated aneurysms: the impact of size, gender, and expansion rate. J Vasc Surg. 2003;37:280-284.
5. Powell JT, Sweeting MJ, Brown LC, Gotensparre SM, Fowkes FG, Thompson SG. Systematic review and meta-analysis of growth rates of small abdominal aortic aneurysms. British Journal of Surgery. 2011;98:609-618.
6. Brown LC, Powell JT. Risk factors for aneurysm rupture in patients kept under ultrasound surveillance. UK Small Aneurysm Trial Participants. Ann Surg. 1999;230(3):289-297.
7. Baxter BT, Terrin MC, Dalman RL. Medical management of small abdominal aortic aneurysms. Circulation. 2008;117:1883-1889.
8. The Propranolol Aneurysm Trial Investigators. Propranolol for small abdominal aortic aneurysms: results of a randomized trial. J Vasc Surg. 2002:35:72-79.
9. Ruhani G, Robertson L, Clarke M. Medical treatment for small abdominal aortic aneurysms. Cochrane Database for Systematic Reviews 2012. Sep 12;9:CD009536. doi: 10.1002/14651858.
10. The United Kingdom EVAR Trial Investigators. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med. 2010; 362:1863-1871.
11. De Bruin JL, Baas AF, Buth J, et al. Long-term outcome of open or endovascular repair of abdominal aortic aneurysm. N Engl J Med. 2010;362:1881-1889.
12. Jackson RS, Chang DC, Freischlag JA. Comparison of long-term survival after open vs. endovascular repair of intact abdominal aortic aneurysm among Medicare beneficiaries. JAMA. 2012;307(15):1621-1628.
13. Biancari F, Catania A, D’Andrea V. Elective endovascular vs. open repair of abdominal aortic aneurysm in patients aged 80 years and older: systematic review and meta-analysis. Eur J Vasc Endovasc Surg. 2011;42:571-576.
14. Schermerhorn ML, O’Malley AJ, Jhaveri A, Cotterill P, Pomposelli F, Landon BE. Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population. N Engl J Med. 2008;358:464-474.
15. Cosford PA, Leng GC, Tomas J. Screening for abdominal aortic aneurysm. Cochrane Database for Systematic Reviews 2007, Issue 2. Art. No.: CD002945. DOI: 10.1002/14651858.CD002945.pub2.
16. Filardo G, Powell JT, Martinez MA, Ballard DJ. Surgery for small asymptomatic abdominal aortic aneurysms. Cochrane Database for Systematic Reviews 2012, Issue 3. Art. No.:CD001835. DOI: 10.1002/14651858.CD001835.pub3.
17. The UK Small Aneurysm Trial Participants. Final 12-year follow-up of surgery versus surveillance in the UK small aneurysm trial. Brit J Surg. 2007;94:702-708.
18. U.S. Preventive Services Task Force. Screening for Abdominal Aortic Aneurysm: Recommendation Statement. AHRQ Publication No. 05-0569-A, February 2005.

Policymakers believe that publicly reporting healthcare performance results is essential to improving care delivery. In order to achieve a healthcare system that is consistently reliable, the Institute of Medicine (IOM) recently recommended that performance transparency be considered a foundational feature of healthcare systems that seek to constantly, systematically, and seamlessly improve.¹ The IOM has suggested strategies (see Table 1, right) for producing readily available information on safety, quality, prices and cost, and health outcomes. As these strategies are being deployed, it is essential that hospitalists consider the impact they will have on their personal practice, key stakeholders, and the patients that they serve.

Performance Data Sources

The accessibility of publicly reported healthcare performance information is increasing rapidly. Among HM practitioners, perhaps the most widely recognized data source is the Centers for Medicare & Medicaid Services’ (CMS) Hospital Compare website (www.hospitalcompare.hhs.gov). According to CMS, its performance information on more than 4,000 hospitals is intended to help patients make decisions about where to seek healthcare, as well as encourage hospitals to improve the quality of care they provide.

The information currently reported is extensive and comprehensive (see Table 2, right). Furthermore, CMS continually adds data as new performance measures are created and validated.

Beyond the federal government, private health insurance companies, consortiums of employer purchasers of healthcare (e.g. the Leapfrog Group), and community collaboratives (e.g. Minnesota Community Measurement in the state of Minnesota) are reporting care provider performance information.

In addition, consumer advocacy groups have entered the picture. Earlier this year, Consumer Reports magazine launched an initiative to rate the quality of hospitals (and cardiac surgery groups) through the publication of patient outcomes (central-line-associated bloodstream infections, surgical site infections, readmissions, complications, mortality), patient experience (communications about medications and discharge, and other markers of satisfaction), and hospital best practices (use of EHR, and the appropriate use of abdominal and chest CT scanning). Consumer Reports also provides a composite hospital safety score, and a 36-page technical manual explaining the strategy and methodology behind their ratings.

Public performance reporting is furthermore becoming big business for healthcare entrepreneurs. Castlight Health, with its $181 million in private capital backing, is viewed by some as the “Travelocity of healthcare.” Castlight calls its searchable databases “transparency portals” that allow consumers to understand, before they visit a care provider, what they will be paying and how the care provider ranks on quality and outcomes.

Finally, numerous unregulated Internet sites that employ methodologically questionable practices are reporting on healthcare performance. Many of these sources collect and publish subjective reports of care experiences, with little or no requirement that the reporter confirm the nature of the relationship that they have with the care provider.

Transparency and Key Stakeholders

The hospital that you work in expects you to know how it performs, and to help it improve in the areas over which you have influence. Hospitals monitor publicly reported data because their futures depend on strong performance. As of October 2012, hospital Medicare reimbursement is linked to publicly reported performance measures that were incorporated into CMS’ value-based purchasing (VBP) initiative. Furthermore, hospital market share will be increasingly dependent on performance transparency as consumers and patients utilize these data to make informed decisions about where to seek high-value healthcare.

Patients have a vested interest in knowing how their care providers perform. A recent study by PricewaterhouseCoopers reported that 72% of consumers ranked provider reputation and personal experience as the top drivers of provider choice.² Furthermore, employers and patients increasingly are demanding access to care affordability information—an interest driven in large part by the increasing popularity of consumer-directed health insurance plans (CDHPs). Under CDHPs, patients save money on premiums in exchange for higher deductibles that are typically paired with healthcare spending accounts. The intent is to increase consumer engagement and awareness of the cost of routine healthcare expenses while protecting against the cost of catastrophic events. It is estimated that 15% to 20% of people with employer-sponsored health insurance are in high-deductible plans, and many believe CDHPs will soon make up the majority of employer-provided coverage.

Patients interested in knowing how individual doctors perform will soon have increased access to this type of information as well. For example, CMS also produces a Physician Compare website (www.medicare.gov/find-a-doctor) that offers performance information on individual doctors. Currently, Physician Compare has little detailed information. Expect this to change, however, as Medicare moves forward with developing valid and reliable individual physician performance metrics for its Physician Value-Based Payment Modifier (VBPM) program (see “A New Measuring Stick,”).

Under VBPM, doctors will have payment modifiers assigned to their Medicare professional fee claims that will adjust payments based on the value of care that they have delivered historically. For example, it is possible in the future that physicians failing to prescribe ace inhibitors to heart failure patients will be paid less than physicians who universally provide evidence-based, best-practice heart failure care. The measurement period for the calculation of these modifiers begins this year, and hospitalists need to be aware that their performance after this time period might affect the amount of Medicare professional fee reimbursement they receive in the future.

Conclusions

Public performance reporting is a keystone healthcare reform strategy that will influence the behavior and practice patterns of hospitals and hospitalists. Hospitalists should regularly review publicly reported healthcare performance data, and commit to working collaboratively with colleagues to capitalize on improvement opportunities suggested by these data.

Dr. Frost is president of SHM.

References

1. Institute of Medicine. Best care at lower cost: The path to continuously learning health care in America. Institute of Medicine website. Available at: http://www.iom.edu/bestcare. Accessed Nov. 24, 2012.
2. PricewaterhouseCoopers’ Health Research Institute. Customer experience in healthcare: the moment of truth. PricewaterhouseCoopers website. Available at: http://www.pwc.com/es_MX/mx/publicaciones/archivo/2012-09-customer-experience-healthcare.pdf. Accessed Nov. 25, 2012.

Policymakers believe that publicly reporting healthcare performance results is essential to improving care delivery. In order to achieve a healthcare system that is consistently reliable, the Institute of Medicine (IOM) recently recommended that performance transparency be considered a foundational feature of healthcare systems that seek to constantly, systematically, and seamlessly improve.¹ The IOM has suggested strategies (see Table 1, right) for producing readily available information on safety, quality, prices and cost, and health outcomes. As these strategies are being deployed, it is essential that hospitalists consider the impact they will have on their personal practice, key stakeholders, and the patients that they serve.

Performance Data Sources

The accessibility of publicly reported healthcare performance information is increasing rapidly. Among HM practitioners, perhaps the most widely recognized data source is the Centers for Medicare & Medicaid Services’ (CMS) Hospital Compare website (www.hospitalcompare.hhs.gov). According to CMS, its performance information on more than 4,000 hospitals is intended to help patients make decisions about where to seek healthcare, as well as encourage hospitals to improve the quality of care they provide.

The information currently reported is extensive and comprehensive (see Table 2, right). Furthermore, CMS continually adds data as new performance measures are created and validated.

Beyond the federal government, private health insurance companies, consortiums of employer purchasers of healthcare (e.g. the Leapfrog Group), and community collaboratives (e.g. Minnesota Community Measurement in the state of Minnesota) are reporting care provider performance information.

In addition, consumer advocacy groups have entered the picture. Earlier this year, Consumer Reports magazine launched an initiative to rate the quality of hospitals (and cardiac surgery groups) through the publication of patient outcomes (central-line-associated bloodstream infections, surgical site infections, readmissions, complications, mortality), patient experience (communications about medications and discharge, and other markers of satisfaction), and hospital best practices (use of EHR, and the appropriate use of abdominal and chest CT scanning). Consumer Reports also provides a composite hospital safety score, and a 36-page technical manual explaining the strategy and methodology behind their ratings.

Public performance reporting is furthermore becoming big business for healthcare entrepreneurs. Castlight Health, with its $181 million in private capital backing, is viewed by some as the “Travelocity of healthcare.” Castlight calls its searchable databases “transparency portals” that allow consumers to understand, before they visit a care provider, what they will be paying and how the care provider ranks on quality and outcomes.

Finally, numerous unregulated Internet sites that employ methodologically questionable practices are reporting on healthcare performance. Many of these sources collect and publish subjective reports of care experiences, with little or no requirement that the reporter confirm the nature of the relationship that they have with the care provider.

Transparency and Key Stakeholders

The hospital that you work in expects you to know how it performs, and to help it improve in the areas over which you have influence. Hospitals monitor publicly reported data because their futures depend on strong performance. As of October 2012, hospital Medicare reimbursement is linked to publicly reported performance measures that were incorporated into CMS’ value-based purchasing (VBP) initiative. Furthermore, hospital market share will be increasingly dependent on performance transparency as consumers and patients utilize these data to make informed decisions about where to seek high-value healthcare.

Patients have a vested interest in knowing how their care providers perform. A recent study by PricewaterhouseCoopers reported that 72% of consumers ranked provider reputation and personal experience as the top drivers of provider choice.² Furthermore, employers and patients increasingly are demanding access to care affordability information—an interest driven in large part by the increasing popularity of consumer-directed health insurance plans (CDHPs). Under CDHPs, patients save money on premiums in exchange for higher deductibles that are typically paired with healthcare spending accounts. The intent is to increase consumer engagement and awareness of the cost of routine healthcare expenses while protecting against the cost of catastrophic events. It is estimated that 15% to 20% of people with employer-sponsored health insurance are in high-deductible plans, and many believe CDHPs will soon make up the majority of employer-provided coverage.

Patients interested in knowing how individual doctors perform will soon have increased access to this type of information as well. For example, CMS also produces a Physician Compare website (www.medicare.gov/find-a-doctor) that offers performance information on individual doctors. Currently, Physician Compare has little detailed information. Expect this to change, however, as Medicare moves forward with developing valid and reliable individual physician performance metrics for its Physician Value-Based Payment Modifier (VBPM) program (see “A New Measuring Stick,”).

Under VBPM, doctors will have payment modifiers assigned to their Medicare professional fee claims that will adjust payments based on the value of care that they have delivered historically. For example, it is possible in the future that physicians failing to prescribe ace inhibitors to heart failure patients will be paid less than physicians who universally provide evidence-based, best-practice heart failure care. The measurement period for the calculation of these modifiers begins this year, and hospitalists need to be aware that their performance after this time period might affect the amount of Medicare professional fee reimbursement they receive in the future.

Conclusions

Public performance reporting is a keystone healthcare reform strategy that will influence the behavior and practice patterns of hospitals and hospitalists. Hospitalists should regularly review publicly reported healthcare performance data, and commit to working collaboratively with colleagues to capitalize on improvement opportunities suggested by these data.

Dr. Frost is president of SHM.

References

1. Institute of Medicine. Best care at lower cost: The path to continuously learning health care in America. Institute of Medicine website. Available at: http://www.iom.edu/bestcare. Accessed Nov. 24, 2012.
2. PricewaterhouseCoopers’ Health Research Institute. Customer experience in healthcare: the moment of truth. PricewaterhouseCoopers website. Available at: http://www.pwc.com/es_MX/mx/publicaciones/archivo/2012-09-customer-experience-healthcare.pdf. Accessed Nov. 25, 2012.

Policymakers believe that publicly reporting healthcare performance results is essential to improving care delivery. In order to achieve a healthcare system that is consistently reliable, the Institute of Medicine (IOM) recently recommended that performance transparency be considered a foundational feature of healthcare systems that seek to constantly, systematically, and seamlessly improve.¹ The IOM has suggested strategies (see Table 1, right) for producing readily available information on safety, quality, prices and cost, and health outcomes. As these strategies are being deployed, it is essential that hospitalists consider the impact they will have on their personal practice, key stakeholders, and the patients that they serve.

Performance Data Sources

The accessibility of publicly reported healthcare performance information is increasing rapidly. Among HM practitioners, perhaps the most widely recognized data source is the Centers for Medicare & Medicaid Services’ (CMS) Hospital Compare website (www.hospitalcompare.hhs.gov). According to CMS, its performance information on more than 4,000 hospitals is intended to help patients make decisions about where to seek healthcare, as well as encourage hospitals to improve the quality of care they provide.

The information currently reported is extensive and comprehensive (see Table 2, right). Furthermore, CMS continually adds data as new performance measures are created and validated.

Beyond the federal government, private health insurance companies, consortiums of employer purchasers of healthcare (e.g. the Leapfrog Group), and community collaboratives (e.g. Minnesota Community Measurement in the state of Minnesota) are reporting care provider performance information.

In addition, consumer advocacy groups have entered the picture. Earlier this year, Consumer Reports magazine launched an initiative to rate the quality of hospitals (and cardiac surgery groups) through the publication of patient outcomes (central-line-associated bloodstream infections, surgical site infections, readmissions, complications, mortality), patient experience (communications about medications and discharge, and other markers of satisfaction), and hospital best practices (use of EHR, and the appropriate use of abdominal and chest CT scanning). Consumer Reports also provides a composite hospital safety score, and a 36-page technical manual explaining the strategy and methodology behind their ratings.

Public performance reporting is furthermore becoming big business for healthcare entrepreneurs. Castlight Health, with its $181 million in private capital backing, is viewed by some as the “Travelocity of healthcare.” Castlight calls its searchable databases “transparency portals” that allow consumers to understand, before they visit a care provider, what they will be paying and how the care provider ranks on quality and outcomes.

Finally, numerous unregulated Internet sites that employ methodologically questionable practices are reporting on healthcare performance. Many of these sources collect and publish subjective reports of care experiences, with little or no requirement that the reporter confirm the nature of the relationship that they have with the care provider.

Transparency and Key Stakeholders

The hospital that you work in expects you to know how it performs, and to help it improve in the areas over which you have influence. Hospitals monitor publicly reported data because their futures depend on strong performance. As of October 2012, hospital Medicare reimbursement is linked to publicly reported performance measures that were incorporated into CMS’ value-based purchasing (VBP) initiative. Furthermore, hospital market share will be increasingly dependent on performance transparency as consumers and patients utilize these data to make informed decisions about where to seek high-value healthcare.

Patients have a vested interest in knowing how their care providers perform. A recent study by PricewaterhouseCoopers reported that 72% of consumers ranked provider reputation and personal experience as the top drivers of provider choice.² Furthermore, employers and patients increasingly are demanding access to care affordability information—an interest driven in large part by the increasing popularity of consumer-directed health insurance plans (CDHPs). Under CDHPs, patients save money on premiums in exchange for higher deductibles that are typically paired with healthcare spending accounts. The intent is to increase consumer engagement and awareness of the cost of routine healthcare expenses while protecting against the cost of catastrophic events. It is estimated that 15% to 20% of people with employer-sponsored health insurance are in high-deductible plans, and many believe CDHPs will soon make up the majority of employer-provided coverage.

Patients interested in knowing how individual doctors perform will soon have increased access to this type of information as well. For example, CMS also produces a Physician Compare website (www.medicare.gov/find-a-doctor) that offers performance information on individual doctors. Currently, Physician Compare has little detailed information. Expect this to change, however, as Medicare moves forward with developing valid and reliable individual physician performance metrics for its Physician Value-Based Payment Modifier (VBPM) program (see “A New Measuring Stick,”).

Under VBPM, doctors will have payment modifiers assigned to their Medicare professional fee claims that will adjust payments based on the value of care that they have delivered historically. For example, it is possible in the future that physicians failing to prescribe ace inhibitors to heart failure patients will be paid less than physicians who universally provide evidence-based, best-practice heart failure care. The measurement period for the calculation of these modifiers begins this year, and hospitalists need to be aware that their performance after this time period might affect the amount of Medicare professional fee reimbursement they receive in the future.

Conclusions

Public performance reporting is a keystone healthcare reform strategy that will influence the behavior and practice patterns of hospitals and hospitalists. Hospitalists should regularly review publicly reported healthcare performance data, and commit to working collaboratively with colleagues to capitalize on improvement opportunities suggested by these data.

Dr. Frost is president of SHM.

References

1. Institute of Medicine. Best care at lower cost: The path to continuously learning health care in America. Institute of Medicine website. Available at: http://www.iom.edu/bestcare. Accessed Nov. 24, 2012.
2. PricewaterhouseCoopers’ Health Research Institute. Customer experience in healthcare: the moment of truth. PricewaterhouseCoopers website. Available at: http://www.pwc.com/es_MX/mx/publicaciones/archivo/2012-09-customer-experience-healthcare.pdf. Accessed Nov. 25, 2012.

As the Obama administration begins its second term, a great deal of attention is being paid to the advance of its healthcare reform agenda. Long overdue for reform is the sustainable growth rate (SGR) formula—an ill-fated attempt to provide predictable control for federal spending on Medicare by providing yearly updates (i.e. reductions) to Medicare’s physician reimbursement rates.

By adjusting the payment rates, the SGR was supposed to help control the cost of healthcare by linking it more closely with national growth and changes in the Medicare-eligible population. With each passing year, however, bipartisan consensus has grown stronger, the message being that a straight, fee-for-service system that is updated annually based on an expenditure target cannot substitute for fundamental delivery system reforms.

Genzink

Congress has acted to override the SGR’s implementation every year since 2003, with the latest round being a potential 27% gutting of Medicare reimbursement rates. This cycle is not only tiresome, but threatens a massive disruption to physician practices and to seniors’ access to the Medicare program.

“The SGR, while well-intentioned, is flawed, and Congress can provide its temporary override for only so long, while Medicare spending continues to grow,” says Ryan Genzink, PA-C, an SHM Public Policy Committee member and a physician assistant with IPC: The Hospitalist Co. in Grand Rapids, Mich.

Repeal and Reform

Although various SGR repeal bills have been introduced over the years, only one—the Medicare Physician Payment Innovation Act of 2012 (H.R. 5707)—supplements repeal with a realistic plan to move away from the current fee-for-service payment system (and its inherent inefficiencies) toward more cost-effective reimbursement models that are designed to promote quality and value through coordinated patient care.

This bipartisan bill, introduced by U.S. Reps. Allyson Schwartz (D-Pa.) and Joe Heck, DO (R-Nev.), would repeal the SGR, stabilize payments at current rates for 2013, replace scheduled reductions with positive and predictable updates from 2014 to 2017, and set an aggressive timetable for testing and evaluating new payment systems focused on improving quality and reducing costs (see “Specific Components of the Schwartz-Heck Proposal,” left). The bill is expected to be reintroduced in 2013.

“SHM agrees that it is time finally to eliminate the SGR and move away from the prevailing fee-for-service payment system, which rewards physicians for simply providing more services, to one that provides incentives to deliver higher-quality, cost-effective care to our nation’s seniors,” wrote SHM President Shaun Frost, MD, SFHM, in a letter of support last year to Schwartz and Heck, commending them for introducing their bill.

“By providing a menu of options for physician participation, including an alternative, value-driven fee-for-service system for physicians who are not able to participate in one of the new payment and delivery models, the legislation does not force all providers into a ‘one size fits all’ solution, allowing for broader support, innovation, and flexibility,” Dr. Frost said.

Advancing New Reimbursement Models

The Schwartz-Heck bill “gives a timeline for CMS to test and adopt different reimbursement models, which presents advantageous options for hospitalists,” says Lauren Doctoroff, MD, an SHM Public Policy Committee member, hospitalist, and medical director of the post-discharge clinic at Beth Israel Deaconess Medical Center in Boston. “Hospitalists already focus on providing higher-quality, lower-cost care to hospitalized patients in their daily practice. We build effective care transitions to the outpatient and extended care settings. Our strengths are perfectly aligned to help these new, value-based payment models succeed.”

Dr. Doctoroff

In fact, Dr. Doctoroff notes, Beth Israel is a participant in CMS’ Medicare Pioneer Accountable Care Organization project as well as Massachusetts Blue Cross Blue Shield’s Alternative Quality Contract, both of which use a risk-sharing global payment model in which the hospital and its physician network agree to provide for the healthcare needs of a defined population for a pre-arranged reimbursement amount.

“The global payment model is an attractive one for hospitalists because we play a key role in managing hospitalized patients efficiently and well, while also encouraging collaboration between inpatient and outpatient providers to avoid duplication of services,” Dr. Doctoroff says. “Some bundled payment models, which tie reimbursement to a defined episode of care, also could be advantageous for hospitalists, who coordinate the patient’s care throughout their entire healthcare episode, from inpatient diagnosis through post-discharge.”

Alternative Fee-for-Service System

For physicians who choose not to adopt one of the new reimbursement models, the bill directs CMS to offer an alternative fee-for-service system with incentives for improved quality and lower cost. This alternative would be available to physicians (including hospitalists) who participate in approved quality-reporting options, including the Physician Quality Reporting System (PQRS) or an approved Maintenance of Certification (MOC) program with quality registries. It also would apply to physicians who fall into the top 25% of CMS’ Value-Based Payment Modifier program (VBPM).

Boosting Primary Care

In addition to expediting the rollout of CMS-endorsed alternate payment models, the Schwartz bill recognizes the importance of primary care as the foundation of an effective healthcare delivery system and redresses its undervaluation with a 2.5% reimbursement update for physicians and other healthcare professionals for whom 60% of their Medicare physician fee schedule allowable charges are from a designated set of primary-care, preventive, and care-coordination codes.

“SHM specifically advocated for the inclusion of primary-care billing codes that hospitalists use,” Dr. Doctoroff says, “including hospital inpatient visits and observational services.”

“Of all the attempts to deal with the SGR over the past several years, Rep. Schwartz’s bill makes the most sense,” Genzink says. “While it doesn’t answer all of the healthcare system’s problems, it encapsulates many of the goals of reform—especially the shift from fee-for-service toward a payment system based on quality and outcomes. It recognizes that no one model will work for all physicians and offers the flexibility of multiple pathways. And it has bipartisan support, which seems to be a rarity these days.”

Chris Guadagnino is a freelance medical writer in Philadelphia.

As the Obama administration begins its second term, a great deal of attention is being paid to the advance of its healthcare reform agenda. Long overdue for reform is the sustainable growth rate (SGR) formula—an ill-fated attempt to provide predictable control for federal spending on Medicare by providing yearly updates (i.e. reductions) to Medicare’s physician reimbursement rates.

By adjusting the payment rates, the SGR was supposed to help control the cost of healthcare by linking it more closely with national growth and changes in the Medicare-eligible population. With each passing year, however, bipartisan consensus has grown stronger, the message being that a straight, fee-for-service system that is updated annually based on an expenditure target cannot substitute for fundamental delivery system reforms.

Genzink

Congress has acted to override the SGR’s implementation every year since 2003, with the latest round being a potential 27% gutting of Medicare reimbursement rates. This cycle is not only tiresome, but threatens a massive disruption to physician practices and to seniors’ access to the Medicare program.

“The SGR, while well-intentioned, is flawed, and Congress can provide its temporary override for only so long, while Medicare spending continues to grow,” says Ryan Genzink, PA-C, an SHM Public Policy Committee member and a physician assistant with IPC: The Hospitalist Co. in Grand Rapids, Mich.

Repeal and Reform

Although various SGR repeal bills have been introduced over the years, only one—the Medicare Physician Payment Innovation Act of 2012 (H.R. 5707)—supplements repeal with a realistic plan to move away from the current fee-for-service payment system (and its inherent inefficiencies) toward more cost-effective reimbursement models that are designed to promote quality and value through coordinated patient care.

This bipartisan bill, introduced by U.S. Reps. Allyson Schwartz (D-Pa.) and Joe Heck, DO (R-Nev.), would repeal the SGR, stabilize payments at current rates for 2013, replace scheduled reductions with positive and predictable updates from 2014 to 2017, and set an aggressive timetable for testing and evaluating new payment systems focused on improving quality and reducing costs (see “Specific Components of the Schwartz-Heck Proposal,” left). The bill is expected to be reintroduced in 2013.

“SHM agrees that it is time finally to eliminate the SGR and move away from the prevailing fee-for-service payment system, which rewards physicians for simply providing more services, to one that provides incentives to deliver higher-quality, cost-effective care to our nation’s seniors,” wrote SHM President Shaun Frost, MD, SFHM, in a letter of support last year to Schwartz and Heck, commending them for introducing their bill.

“By providing a menu of options for physician participation, including an alternative, value-driven fee-for-service system for physicians who are not able to participate in one of the new payment and delivery models, the legislation does not force all providers into a ‘one size fits all’ solution, allowing for broader support, innovation, and flexibility,” Dr. Frost said.

Advancing New Reimbursement Models

The Schwartz-Heck bill “gives a timeline for CMS to test and adopt different reimbursement models, which presents advantageous options for hospitalists,” says Lauren Doctoroff, MD, an SHM Public Policy Committee member, hospitalist, and medical director of the post-discharge clinic at Beth Israel Deaconess Medical Center in Boston. “Hospitalists already focus on providing higher-quality, lower-cost care to hospitalized patients in their daily practice. We build effective care transitions to the outpatient and extended care settings. Our strengths are perfectly aligned to help these new, value-based payment models succeed.”

Dr. Doctoroff

In fact, Dr. Doctoroff notes, Beth Israel is a participant in CMS’ Medicare Pioneer Accountable Care Organization project as well as Massachusetts Blue Cross Blue Shield’s Alternative Quality Contract, both of which use a risk-sharing global payment model in which the hospital and its physician network agree to provide for the healthcare needs of a defined population for a pre-arranged reimbursement amount.

“The global payment model is an attractive one for hospitalists because we play a key role in managing hospitalized patients efficiently and well, while also encouraging collaboration between inpatient and outpatient providers to avoid duplication of services,” Dr. Doctoroff says. “Some bundled payment models, which tie reimbursement to a defined episode of care, also could be advantageous for hospitalists, who coordinate the patient’s care throughout their entire healthcare episode, from inpatient diagnosis through post-discharge.”

Alternative Fee-for-Service System

For physicians who choose not to adopt one of the new reimbursement models, the bill directs CMS to offer an alternative fee-for-service system with incentives for improved quality and lower cost. This alternative would be available to physicians (including hospitalists) who participate in approved quality-reporting options, including the Physician Quality Reporting System (PQRS) or an approved Maintenance of Certification (MOC) program with quality registries. It also would apply to physicians who fall into the top 25% of CMS’ Value-Based Payment Modifier program (VBPM).

Boosting Primary Care

In addition to expediting the rollout of CMS-endorsed alternate payment models, the Schwartz bill recognizes the importance of primary care as the foundation of an effective healthcare delivery system and redresses its undervaluation with a 2.5% reimbursement update for physicians and other healthcare professionals for whom 60% of their Medicare physician fee schedule allowable charges are from a designated set of primary-care, preventive, and care-coordination codes.

“SHM specifically advocated for the inclusion of primary-care billing codes that hospitalists use,” Dr. Doctoroff says, “including hospital inpatient visits and observational services.”

“Of all the attempts to deal with the SGR over the past several years, Rep. Schwartz’s bill makes the most sense,” Genzink says. “While it doesn’t answer all of the healthcare system’s problems, it encapsulates many of the goals of reform—especially the shift from fee-for-service toward a payment system based on quality and outcomes. It recognizes that no one model will work for all physicians and offers the flexibility of multiple pathways. And it has bipartisan support, which seems to be a rarity these days.”

Chris Guadagnino is a freelance medical writer in Philadelphia.

As the Obama administration begins its second term, a great deal of attention is being paid to the advance of its healthcare reform agenda. Long overdue for reform is the sustainable growth rate (SGR) formula—an ill-fated attempt to provide predictable control for federal spending on Medicare by providing yearly updates (i.e. reductions) to Medicare’s physician reimbursement rates.

By adjusting the payment rates, the SGR was supposed to help control the cost of healthcare by linking it more closely with national growth and changes in the Medicare-eligible population. With each passing year, however, bipartisan consensus has grown stronger, the message being that a straight, fee-for-service system that is updated annually based on an expenditure target cannot substitute for fundamental delivery system reforms.

Genzink

Congress has acted to override the SGR’s implementation every year since 2003, with the latest round being a potential 27% gutting of Medicare reimbursement rates. This cycle is not only tiresome, but threatens a massive disruption to physician practices and to seniors’ access to the Medicare program.

“The SGR, while well-intentioned, is flawed, and Congress can provide its temporary override for only so long, while Medicare spending continues to grow,” says Ryan Genzink, PA-C, an SHM Public Policy Committee member and a physician assistant with IPC: The Hospitalist Co. in Grand Rapids, Mich.

Repeal and Reform

Although various SGR repeal bills have been introduced over the years, only one—the Medicare Physician Payment Innovation Act of 2012 (H.R. 5707)—supplements repeal with a realistic plan to move away from the current fee-for-service payment system (and its inherent inefficiencies) toward more cost-effective reimbursement models that are designed to promote quality and value through coordinated patient care.

This bipartisan bill, introduced by U.S. Reps. Allyson Schwartz (D-Pa.) and Joe Heck, DO (R-Nev.), would repeal the SGR, stabilize payments at current rates for 2013, replace scheduled reductions with positive and predictable updates from 2014 to 2017, and set an aggressive timetable for testing and evaluating new payment systems focused on improving quality and reducing costs (see “Specific Components of the Schwartz-Heck Proposal,” left). The bill is expected to be reintroduced in 2013.

“SHM agrees that it is time finally to eliminate the SGR and move away from the prevailing fee-for-service payment system, which rewards physicians for simply providing more services, to one that provides incentives to deliver higher-quality, cost-effective care to our nation’s seniors,” wrote SHM President Shaun Frost, MD, SFHM, in a letter of support last year to Schwartz and Heck, commending them for introducing their bill.

“By providing a menu of options for physician participation, including an alternative, value-driven fee-for-service system for physicians who are not able to participate in one of the new payment and delivery models, the legislation does not force all providers into a ‘one size fits all’ solution, allowing for broader support, innovation, and flexibility,” Dr. Frost said.

Advancing New Reimbursement Models

The Schwartz-Heck bill “gives a timeline for CMS to test and adopt different reimbursement models, which presents advantageous options for hospitalists,” says Lauren Doctoroff, MD, an SHM Public Policy Committee member, hospitalist, and medical director of the post-discharge clinic at Beth Israel Deaconess Medical Center in Boston. “Hospitalists already focus on providing higher-quality, lower-cost care to hospitalized patients in their daily practice. We build effective care transitions to the outpatient and extended care settings. Our strengths are perfectly aligned to help these new, value-based payment models succeed.”

Dr. Doctoroff

In fact, Dr. Doctoroff notes, Beth Israel is a participant in CMS’ Medicare Pioneer Accountable Care Organization project as well as Massachusetts Blue Cross Blue Shield’s Alternative Quality Contract, both of which use a risk-sharing global payment model in which the hospital and its physician network agree to provide for the healthcare needs of a defined population for a pre-arranged reimbursement amount.

“The global payment model is an attractive one for hospitalists because we play a key role in managing hospitalized patients efficiently and well, while also encouraging collaboration between inpatient and outpatient providers to avoid duplication of services,” Dr. Doctoroff says. “Some bundled payment models, which tie reimbursement to a defined episode of care, also could be advantageous for hospitalists, who coordinate the patient’s care throughout their entire healthcare episode, from inpatient diagnosis through post-discharge.”

Alternative Fee-for-Service System

For physicians who choose not to adopt one of the new reimbursement models, the bill directs CMS to offer an alternative fee-for-service system with incentives for improved quality and lower cost. This alternative would be available to physicians (including hospitalists) who participate in approved quality-reporting options, including the Physician Quality Reporting System (PQRS) or an approved Maintenance of Certification (MOC) program with quality registries. It also would apply to physicians who fall into the top 25% of CMS’ Value-Based Payment Modifier program (VBPM).

Boosting Primary Care

In addition to expediting the rollout of CMS-endorsed alternate payment models, the Schwartz bill recognizes the importance of primary care as the foundation of an effective healthcare delivery system and redresses its undervaluation with a 2.5% reimbursement update for physicians and other healthcare professionals for whom 60% of their Medicare physician fee schedule allowable charges are from a designated set of primary-care, preventive, and care-coordination codes.

“SHM specifically advocated for the inclusion of primary-care billing codes that hospitalists use,” Dr. Doctoroff says, “including hospital inpatient visits and observational services.”

“Of all the attempts to deal with the SGR over the past several years, Rep. Schwartz’s bill makes the most sense,” Genzink says. “While it doesn’t answer all of the healthcare system’s problems, it encapsulates many of the goals of reform—especially the shift from fee-for-service toward a payment system based on quality and outcomes. It recognizes that no one model will work for all physicians and offers the flexibility of multiple pathways. And it has bipartisan support, which seems to be a rarity these days.”

Chris Guadagnino is a freelance medical writer in Philadelphia.

It’s great to be a Tennessee Volunteer. I said, It’s great to be a Tennessee Volunteer!

The crowd, a sea of orange, packs into Neyland Stadium in Knoxville, Tenn., brimming with pride, dedicated to the team they call the Vols. Neyland Stadium, built in 1921, comfortably seats more than 100,000 brash fans on most fall weekends during the college football season. These die-hard fans pack the stadium regularly, hoping to catch a glimpse of victory.

Throughout the decades of Tennessee Volunteers football, numerous coaches have spent countless hours thinking about how to realize those victories. And they have also spent a lot time thinking about how to keep their players safe. Each coach has had different styles and tactics, but all had one thing in common: They were clearly invested in keeping their players safe. A safe player is a good player, one who can make the full season without injury. As such, before each practice and each game, the players don the gear required to play the safest game possible.

This gear is expensive, difficult to put on, difficult to keep on, makes them run slower, and makes them sweat heavier. When you think about it, it is a wonder that they wear it at all—unless you consider the fact that each precisely placed article takes them one step closer to surviving the game intact, and making it to the next victory. Just like any other type of protective equipment, football equipment has evolved over the course of time. The helmet, for example, is now custom-fit for each player with calipers, and then subsequent additions are applied to ensure durability, shock resistance, and comfort. Relatively new additions include eye shields (to protect the eyes and reduce glare) and even radio devices (to allow the coach to relay last-minute critical information to the quarterback). These helmets are all customized to the players’ position, to allow for the best balance between protection and visibility.

And the helmet is just the beginning. The remaining bare minimum amount of gear needed for standard player safety includes a mouthpiece, jaw pads, neck roll, shoulder pads, shock pads, rib pads, hip pads, knee pads, and cleats. All told, the weight of all this equipment is between 10 and 25 pounds and takes up to an hour to fully gear up. But nonetheless, it has become such a mainstay, of centralized importance to the game, that each team has a dedicated equipment manager. They are charged with providing, maintaining, and transporting the best gear for every member of the team. The equipment manager is a vital resource for the team and the sport.

Despite the extra weight and inconvenience that their gear can burden them with, you don’t see a single football player “skimp” on it. And it would certainly be obvious to all those around them if they ran onto the field without their helmet. Over the years, the football industry has not abandoned gear that they thought was less than perfect, too heavy, too bulky, or made the player perform with less agility. They just made the gear better, lighter, more comfortable, and more protective.

You Can Do This

In a similar fashion, hospital providers have become increasingly interested in keeping themselves—and the patient—safe. But have we come to consensus on who the coach and equipment managers should be, and what the essential elements of the gear should be? I would argue there are a number of coaches and equipment managers in the hospital setting whose mission is to keep their “players” safe. The players are both patients and providers, as generally a “safe provider” is one who makes and implements solid decisions, and who is housed within a safe, predictable, and highly-reliable system, is also one who can and will keep their patients safe.

We may not think of ourselves as such, but hospitalists can be extremely effective coaches and equipment managers. They can help create and maintain safe and effective gear for themselves and those patients and providers around them. They can be a mentor for displaying how vitally import this gear is and can work to improve it when it proves to be imperfect.

Although we don’t tend to think of these things as “safety gear,” these things do, in fact, keep us and our patients safe. Some of these include:

• Computerized physician order entry (CPOE) with decision support (or order sets without CPOE);
• Checklists;
• Procedural time-outs;
• Protocols;
• Medication dosing guidelines;
• Handheld devices (for quick lookup of medication doses, side effects, predictive scoring systems, medical calculators, etc.); and
• Gowns and gloves.

Additional “gear” for the patients can include:

• Arm bands for identification and medication scanning;
• Telemetry;
• Bed alarms;
• IV pumps with guard rails around dosing;
• Antibiotic impregnated central lines; and
• Early mobilization protocols.

The Next Level

To take the medical industry to the next level of safe reliability, we need all providers to accept and embrace the concept of “safety gear” for themselves and for their patients. We need to make it perfectly obvious when that gear is missing. It should invoke a reaction of ghastly fear when we witness anyone (provider, patient, or family) skimping on their gear: removing an armband for convenience, bypassing a smart pump, or skipping decision support in CPOE. And for the current gear that is imperfect, slows us down, beeps too often, or reduces our agility, the solution should include improving the gear, not ignoring it or discounting its importance.

So before you go to work today (every day?), think about what you need to keep yourself and your patients safe. And get your gear on.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at scheured@musc.edu.

It’s great to be a Tennessee Volunteer. I said, It’s great to be a Tennessee Volunteer!

The crowd, a sea of orange, packs into Neyland Stadium in Knoxville, Tenn., brimming with pride, dedicated to the team they call the Vols. Neyland Stadium, built in 1921, comfortably seats more than 100,000 brash fans on most fall weekends during the college football season. These die-hard fans pack the stadium regularly, hoping to catch a glimpse of victory.

Throughout the decades of Tennessee Volunteers football, numerous coaches have spent countless hours thinking about how to realize those victories. And they have also spent a lot time thinking about how to keep their players safe. Each coach has had different styles and tactics, but all had one thing in common: They were clearly invested in keeping their players safe. A safe player is a good player, one who can make the full season without injury. As such, before each practice and each game, the players don the gear required to play the safest game possible.

This gear is expensive, difficult to put on, difficult to keep on, makes them run slower, and makes them sweat heavier. When you think about it, it is a wonder that they wear it at all—unless you consider the fact that each precisely placed article takes them one step closer to surviving the game intact, and making it to the next victory. Just like any other type of protective equipment, football equipment has evolved over the course of time. The helmet, for example, is now custom-fit for each player with calipers, and then subsequent additions are applied to ensure durability, shock resistance, and comfort. Relatively new additions include eye shields (to protect the eyes and reduce glare) and even radio devices (to allow the coach to relay last-minute critical information to the quarterback). These helmets are all customized to the players’ position, to allow for the best balance between protection and visibility.

And the helmet is just the beginning. The remaining bare minimum amount of gear needed for standard player safety includes a mouthpiece, jaw pads, neck roll, shoulder pads, shock pads, rib pads, hip pads, knee pads, and cleats. All told, the weight of all this equipment is between 10 and 25 pounds and takes up to an hour to fully gear up. But nonetheless, it has become such a mainstay, of centralized importance to the game, that each team has a dedicated equipment manager. They are charged with providing, maintaining, and transporting the best gear for every member of the team. The equipment manager is a vital resource for the team and the sport.

Despite the extra weight and inconvenience that their gear can burden them with, you don’t see a single football player “skimp” on it. And it would certainly be obvious to all those around them if they ran onto the field without their helmet. Over the years, the football industry has not abandoned gear that they thought was less than perfect, too heavy, too bulky, or made the player perform with less agility. They just made the gear better, lighter, more comfortable, and more protective.

You Can Do This

In a similar fashion, hospital providers have become increasingly interested in keeping themselves—and the patient—safe. But have we come to consensus on who the coach and equipment managers should be, and what the essential elements of the gear should be? I would argue there are a number of coaches and equipment managers in the hospital setting whose mission is to keep their “players” safe. The players are both patients and providers, as generally a “safe provider” is one who makes and implements solid decisions, and who is housed within a safe, predictable, and highly-reliable system, is also one who can and will keep their patients safe.

We may not think of ourselves as such, but hospitalists can be extremely effective coaches and equipment managers. They can help create and maintain safe and effective gear for themselves and those patients and providers around them. They can be a mentor for displaying how vitally import this gear is and can work to improve it when it proves to be imperfect.

Although we don’t tend to think of these things as “safety gear,” these things do, in fact, keep us and our patients safe. Some of these include:

• Computerized physician order entry (CPOE) with decision support (or order sets without CPOE);
• Checklists;
• Procedural time-outs;
• Protocols;
• Medication dosing guidelines;
• Handheld devices (for quick lookup of medication doses, side effects, predictive scoring systems, medical calculators, etc.); and
• Gowns and gloves.

Additional “gear” for the patients can include:

• Arm bands for identification and medication scanning;
• Telemetry;
• Bed alarms;
• IV pumps with guard rails around dosing;
• Antibiotic impregnated central lines; and
• Early mobilization protocols.

The Next Level

To take the medical industry to the next level of safe reliability, we need all providers to accept and embrace the concept of “safety gear” for themselves and for their patients. We need to make it perfectly obvious when that gear is missing. It should invoke a reaction of ghastly fear when we witness anyone (provider, patient, or family) skimping on their gear: removing an armband for convenience, bypassing a smart pump, or skipping decision support in CPOE. And for the current gear that is imperfect, slows us down, beeps too often, or reduces our agility, the solution should include improving the gear, not ignoring it or discounting its importance.

So before you go to work today (every day?), think about what you need to keep yourself and your patients safe. And get your gear on.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at scheured@musc.edu.

It’s great to be a Tennessee Volunteer. I said, It’s great to be a Tennessee Volunteer!

The crowd, a sea of orange, packs into Neyland Stadium in Knoxville, Tenn., brimming with pride, dedicated to the team they call the Vols. Neyland Stadium, built in 1921, comfortably seats more than 100,000 brash fans on most fall weekends during the college football season. These die-hard fans pack the stadium regularly, hoping to catch a glimpse of victory.

Throughout the decades of Tennessee Volunteers football, numerous coaches have spent countless hours thinking about how to realize those victories. And they have also spent a lot time thinking about how to keep their players safe. Each coach has had different styles and tactics, but all had one thing in common: They were clearly invested in keeping their players safe. A safe player is a good player, one who can make the full season without injury. As such, before each practice and each game, the players don the gear required to play the safest game possible.

This gear is expensive, difficult to put on, difficult to keep on, makes them run slower, and makes them sweat heavier. When you think about it, it is a wonder that they wear it at all—unless you consider the fact that each precisely placed article takes them one step closer to surviving the game intact, and making it to the next victory. Just like any other type of protective equipment, football equipment has evolved over the course of time. The helmet, for example, is now custom-fit for each player with calipers, and then subsequent additions are applied to ensure durability, shock resistance, and comfort. Relatively new additions include eye shields (to protect the eyes and reduce glare) and even radio devices (to allow the coach to relay last-minute critical information to the quarterback). These helmets are all customized to the players’ position, to allow for the best balance between protection and visibility.

And the helmet is just the beginning. The remaining bare minimum amount of gear needed for standard player safety includes a mouthpiece, jaw pads, neck roll, shoulder pads, shock pads, rib pads, hip pads, knee pads, and cleats. All told, the weight of all this equipment is between 10 and 25 pounds and takes up to an hour to fully gear up. But nonetheless, it has become such a mainstay, of centralized importance to the game, that each team has a dedicated equipment manager. They are charged with providing, maintaining, and transporting the best gear for every member of the team. The equipment manager is a vital resource for the team and the sport.

Despite the extra weight and inconvenience that their gear can burden them with, you don’t see a single football player “skimp” on it. And it would certainly be obvious to all those around them if they ran onto the field without their helmet. Over the years, the football industry has not abandoned gear that they thought was less than perfect, too heavy, too bulky, or made the player perform with less agility. They just made the gear better, lighter, more comfortable, and more protective.

You Can Do This

In a similar fashion, hospital providers have become increasingly interested in keeping themselves—and the patient—safe. But have we come to consensus on who the coach and equipment managers should be, and what the essential elements of the gear should be? I would argue there are a number of coaches and equipment managers in the hospital setting whose mission is to keep their “players” safe. The players are both patients and providers, as generally a “safe provider” is one who makes and implements solid decisions, and who is housed within a safe, predictable, and highly-reliable system, is also one who can and will keep their patients safe.

We may not think of ourselves as such, but hospitalists can be extremely effective coaches and equipment managers. They can help create and maintain safe and effective gear for themselves and those patients and providers around them. They can be a mentor for displaying how vitally import this gear is and can work to improve it when it proves to be imperfect.

Although we don’t tend to think of these things as “safety gear,” these things do, in fact, keep us and our patients safe. Some of these include:

• Computerized physician order entry (CPOE) with decision support (or order sets without CPOE);
• Checklists;
• Procedural time-outs;
• Protocols;
• Medication dosing guidelines;
• Handheld devices (for quick lookup of medication doses, side effects, predictive scoring systems, medical calculators, etc.); and
• Gowns and gloves.

Additional “gear” for the patients can include:

• Arm bands for identification and medication scanning;
• Telemetry;
• Bed alarms;
• IV pumps with guard rails around dosing;
• Antibiotic impregnated central lines; and
• Early mobilization protocols.

The Next Level

To take the medical industry to the next level of safe reliability, we need all providers to accept and embrace the concept of “safety gear” for themselves and for their patients. We need to make it perfectly obvious when that gear is missing. It should invoke a reaction of ghastly fear when we witness anyone (provider, patient, or family) skimping on their gear: removing an armband for convenience, bypassing a smart pump, or skipping decision support in CPOE. And for the current gear that is imperfect, slows us down, beeps too often, or reduces our agility, the solution should include improving the gear, not ignoring it or discounting its importance.

So before you go to work today (every day?), think about what you need to keep yourself and your patients safe. And get your gear on.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at scheured@musc.edu.

John Nelson, MD, MHM

Ben was just accepted to med school!!! Hopefully, more acceptances will be forthcoming. We are very proud of Ben for all his hard work. Another doctor in the family.

I was delighted to find the above message from an old friend in my inbox. It got me thinking: Will Ben become a hospitalist? Will he join his dad’s hospitalist group? Will his dad encourage him to pursue a hospitalist career or something else?

Early Hospitalist Practice

The author of that email was Ben’s dad, Chuck Wilson. Chuck is the reason I’m a hospitalist. He was a year ahead of me in residency, and while still a resident, he somehow connected with a really busy family physician in town who was looking for someone to manage his hospital patients. Not one to be bound by convention, Chuck agreed to what was at the time a nearly unheard-of arrangement. He finished residency, joined the staff of the community hospital across town from our residency, and began caring for the family physician’s hospital patients. Within days, he was fielding calls from other doctors asking him to do the same for them. Within weeks of arriving, he had begun accepting essentially all unassigned medical admissions from the ED. This was in the 1980s; Chuck was among the nation’s first real hospitalists.

I don’t think Chuck spent any time worrying about how his practice was so different from the traditional internists and family physicians in the community. He was confident he was providing a valuable service to his patients and the medical community. The rapid growth in his patient census was an indicator he was on to something, and soon he and I began talking. He was looking for a partner.

In November of my third year of residency, I decided I would put off my endocrinology fellowship for a year or two and join Chuck in his new practice. From our conversations, I anticipated that I would care for exactly the kinds of patients that filled nearly all of my time as a resident. I wouldn’t need to learn the new skills in ambulatory medicine, and wouldn’t need to make the long-term commitment expected to join a traditional primary-care practice. And I would earn a competitive compensation and have a flexible lifestyle. I soon realized that hospitalist practice provided me with all of these advantages, so more than two decades later, I still haven’t gotten around to completing the application for an endocrine fellowship.

A Loose Arrangement

For the first few years, Chuck and I didn’t bother to have any sort of legal agreement with each other. We shook hands and agreed to a “reap what you till” form of compensation, which meant we didn’t have to work exactly the same amount, and never had disagreements about how practice revenue was divided between us.

Because of Chuck’s influence, we had miniscule overhead expenses, most likely less than 10% of revenue. We each bought our own malpractice insurance, paid our biller a percent of collections, and rented a pager. That was about it for overhead.

We had no rigid scheduling algorithm, the only requirement being that at least one of us needed to be working every day. Both of us worked most weekdays, but we took time off whenever it suited us. Our scheduling meetings were usually held when we bumped into one another while rounding and went something like this:

“You OK if I take five days off starting tomorrow?”

“Sure. That’s fine.”

Meeting adjourned.

For years, we had no official name for our practice. This became a bigger issue when our group had grown to four doctors, so we defaulted to referring to the group by the first letter of the last name of each doctor, in order of tenure: The WNKL Group. A more formal name was to follow a few years later when the group was even larger, but I’ve taken delight in hearing that WNKL has persisted in some places and documents around the hospital years later, even though N, K, and L left the group long ago.

In the first few years, we never thought about developing clinical protocols or measuring our efficiency or clinical effectiveness. Chuck was confident that compared to the traditional primary-care model, we were providing higher-quality care at a lower cost. But I wasn’t so sure. After a few years, we began seeing hospital data showing that our cost per case tended to be lower, and what little data we could get regarding our quality of care suggested that it was about the same, and in some cases might be better.

A principal reason the practice has survived more than 25 years is that other than a small “tax” during their first 18 months (mainly to cover the cost of recruiting them), new doctors were regarded as equals in the business. Chuck and subsequent doctors never tried to gain an advantage over newer doctors by trying to claim a greater share of the practice’s revenue or decision-making authority.

Chuck is still in the same group he founded. In 2000, I was lured away by the chance to start a new group and live in a place that both my wife and I love. He and I have enjoyed watching our field grow up, and we take satisfaction in our roles in its evolution.

Lessons Learned

The hospitalist model of practice didn’t have a single inventor or place of origin, and anyone involved in starting a practice in the 1980s or before should be proud to have invented their practice when no blueprint existed. Creative thinking and openness to a new way of doing things were critical in developing the first hospitalist practices. They also are useful traits in trying to improve modern hospitalist practices or other segments of our healthcare system.

Like many new developments in medicine, the economic effects of our practice—lower hospital cost per case—became apparent, especially to Chuck, before data regarding quality surfaced. I wish we had gotten more serious early on about capturing whatever quality data might have been available—clearly less than what is available today—and those in new healthcare endeavors today should try to measure quality at the outset. Unlike the 1980s, the current marketplace will help ensure that happens.

Coda

There is one other really cool thing about Chuck’s email at the beginning of this column: those three exclamation points! Chuck is typically laconic and understated, and not given to such displays of emotion, but there are few things that generate more enthusiasm than a parent sharing news of a child’s success.

So, Ben, as you start med school next year, I wish you the best. You can be sure I’ll be asking for updates about your progress. The most important thing is that you find a life and career that engages you to do good work for others and provides satisfaction. And whatever you choose to do after med school, I know you’ll continue to make your parents proud.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is course co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.

John Nelson, MD, MHM

Ben was just accepted to med school!!! Hopefully, more acceptances will be forthcoming. We are very proud of Ben for all his hard work. Another doctor in the family.

I was delighted to find the above message from an old friend in my inbox. It got me thinking: Will Ben become a hospitalist? Will he join his dad’s hospitalist group? Will his dad encourage him to pursue a hospitalist career or something else?

Early Hospitalist Practice

The author of that email was Ben’s dad, Chuck Wilson. Chuck is the reason I’m a hospitalist. He was a year ahead of me in residency, and while still a resident, he somehow connected with a really busy family physician in town who was looking for someone to manage his hospital patients. Not one to be bound by convention, Chuck agreed to what was at the time a nearly unheard-of arrangement. He finished residency, joined the staff of the community hospital across town from our residency, and began caring for the family physician’s hospital patients. Within days, he was fielding calls from other doctors asking him to do the same for them. Within weeks of arriving, he had begun accepting essentially all unassigned medical admissions from the ED. This was in the 1980s; Chuck was among the nation’s first real hospitalists.

I don’t think Chuck spent any time worrying about how his practice was so different from the traditional internists and family physicians in the community. He was confident he was providing a valuable service to his patients and the medical community. The rapid growth in his patient census was an indicator he was on to something, and soon he and I began talking. He was looking for a partner.

In November of my third year of residency, I decided I would put off my endocrinology fellowship for a year or two and join Chuck in his new practice. From our conversations, I anticipated that I would care for exactly the kinds of patients that filled nearly all of my time as a resident. I wouldn’t need to learn the new skills in ambulatory medicine, and wouldn’t need to make the long-term commitment expected to join a traditional primary-care practice. And I would earn a competitive compensation and have a flexible lifestyle. I soon realized that hospitalist practice provided me with all of these advantages, so more than two decades later, I still haven’t gotten around to completing the application for an endocrine fellowship.

A Loose Arrangement

For the first few years, Chuck and I didn’t bother to have any sort of legal agreement with each other. We shook hands and agreed to a “reap what you till” form of compensation, which meant we didn’t have to work exactly the same amount, and never had disagreements about how practice revenue was divided between us.

Because of Chuck’s influence, we had miniscule overhead expenses, most likely less than 10% of revenue. We each bought our own malpractice insurance, paid our biller a percent of collections, and rented a pager. That was about it for overhead.

We had no rigid scheduling algorithm, the only requirement being that at least one of us needed to be working every day. Both of us worked most weekdays, but we took time off whenever it suited us. Our scheduling meetings were usually held when we bumped into one another while rounding and went something like this:

“You OK if I take five days off starting tomorrow?”

“Sure. That’s fine.”

Meeting adjourned.

For years, we had no official name for our practice. This became a bigger issue when our group had grown to four doctors, so we defaulted to referring to the group by the first letter of the last name of each doctor, in order of tenure: The WNKL Group. A more formal name was to follow a few years later when the group was even larger, but I’ve taken delight in hearing that WNKL has persisted in some places and documents around the hospital years later, even though N, K, and L left the group long ago.

In the first few years, we never thought about developing clinical protocols or measuring our efficiency or clinical effectiveness. Chuck was confident that compared to the traditional primary-care model, we were providing higher-quality care at a lower cost. But I wasn’t so sure. After a few years, we began seeing hospital data showing that our cost per case tended to be lower, and what little data we could get regarding our quality of care suggested that it was about the same, and in some cases might be better.

A principal reason the practice has survived more than 25 years is that other than a small “tax” during their first 18 months (mainly to cover the cost of recruiting them), new doctors were regarded as equals in the business. Chuck and subsequent doctors never tried to gain an advantage over newer doctors by trying to claim a greater share of the practice’s revenue or decision-making authority.

Chuck is still in the same group he founded. In 2000, I was lured away by the chance to start a new group and live in a place that both my wife and I love. He and I have enjoyed watching our field grow up, and we take satisfaction in our roles in its evolution.

Lessons Learned

The hospitalist model of practice didn’t have a single inventor or place of origin, and anyone involved in starting a practice in the 1980s or before should be proud to have invented their practice when no blueprint existed. Creative thinking and openness to a new way of doing things were critical in developing the first hospitalist practices. They also are useful traits in trying to improve modern hospitalist practices or other segments of our healthcare system.

Like many new developments in medicine, the economic effects of our practice—lower hospital cost per case—became apparent, especially to Chuck, before data regarding quality surfaced. I wish we had gotten more serious early on about capturing whatever quality data might have been available—clearly less than what is available today—and those in new healthcare endeavors today should try to measure quality at the outset. Unlike the 1980s, the current marketplace will help ensure that happens.

Coda

There is one other really cool thing about Chuck’s email at the beginning of this column: those three exclamation points! Chuck is typically laconic and understated, and not given to such displays of emotion, but there are few things that generate more enthusiasm than a parent sharing news of a child’s success.

So, Ben, as you start med school next year, I wish you the best. You can be sure I’ll be asking for updates about your progress. The most important thing is that you find a life and career that engages you to do good work for others and provides satisfaction. And whatever you choose to do after med school, I know you’ll continue to make your parents proud.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is course co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.

John Nelson, MD, MHM

Ben was just accepted to med school!!! Hopefully, more acceptances will be forthcoming. We are very proud of Ben for all his hard work. Another doctor in the family.

I was delighted to find the above message from an old friend in my inbox. It got me thinking: Will Ben become a hospitalist? Will he join his dad’s hospitalist group? Will his dad encourage him to pursue a hospitalist career or something else?

Early Hospitalist Practice

The author of that email was Ben’s dad, Chuck Wilson. Chuck is the reason I’m a hospitalist. He was a year ahead of me in residency, and while still a resident, he somehow connected with a really busy family physician in town who was looking for someone to manage his hospital patients. Not one to be bound by convention, Chuck agreed to what was at the time a nearly unheard-of arrangement. He finished residency, joined the staff of the community hospital across town from our residency, and began caring for the family physician’s hospital patients. Within days, he was fielding calls from other doctors asking him to do the same for them. Within weeks of arriving, he had begun accepting essentially all unassigned medical admissions from the ED. This was in the 1980s; Chuck was among the nation’s first real hospitalists.

I don’t think Chuck spent any time worrying about how his practice was so different from the traditional internists and family physicians in the community. He was confident he was providing a valuable service to his patients and the medical community. The rapid growth in his patient census was an indicator he was on to something, and soon he and I began talking. He was looking for a partner.

In November of my third year of residency, I decided I would put off my endocrinology fellowship for a year or two and join Chuck in his new practice. From our conversations, I anticipated that I would care for exactly the kinds of patients that filled nearly all of my time as a resident. I wouldn’t need to learn the new skills in ambulatory medicine, and wouldn’t need to make the long-term commitment expected to join a traditional primary-care practice. And I would earn a competitive compensation and have a flexible lifestyle. I soon realized that hospitalist practice provided me with all of these advantages, so more than two decades later, I still haven’t gotten around to completing the application for an endocrine fellowship.

A Loose Arrangement

For the first few years, Chuck and I didn’t bother to have any sort of legal agreement with each other. We shook hands and agreed to a “reap what you till” form of compensation, which meant we didn’t have to work exactly the same amount, and never had disagreements about how practice revenue was divided between us.

Because of Chuck’s influence, we had miniscule overhead expenses, most likely less than 10% of revenue. We each bought our own malpractice insurance, paid our biller a percent of collections, and rented a pager. That was about it for overhead.

We had no rigid scheduling algorithm, the only requirement being that at least one of us needed to be working every day. Both of us worked most weekdays, but we took time off whenever it suited us. Our scheduling meetings were usually held when we bumped into one another while rounding and went something like this:

“You OK if I take five days off starting tomorrow?”

“Sure. That’s fine.”

Meeting adjourned.

For years, we had no official name for our practice. This became a bigger issue when our group had grown to four doctors, so we defaulted to referring to the group by the first letter of the last name of each doctor, in order of tenure: The WNKL Group. A more formal name was to follow a few years later when the group was even larger, but I’ve taken delight in hearing that WNKL has persisted in some places and documents around the hospital years later, even though N, K, and L left the group long ago.

In the first few years, we never thought about developing clinical protocols or measuring our efficiency or clinical effectiveness. Chuck was confident that compared to the traditional primary-care model, we were providing higher-quality care at a lower cost. But I wasn’t so sure. After a few years, we began seeing hospital data showing that our cost per case tended to be lower, and what little data we could get regarding our quality of care suggested that it was about the same, and in some cases might be better.

A principal reason the practice has survived more than 25 years is that other than a small “tax” during their first 18 months (mainly to cover the cost of recruiting them), new doctors were regarded as equals in the business. Chuck and subsequent doctors never tried to gain an advantage over newer doctors by trying to claim a greater share of the practice’s revenue or decision-making authority.

Chuck is still in the same group he founded. In 2000, I was lured away by the chance to start a new group and live in a place that both my wife and I love. He and I have enjoyed watching our field grow up, and we take satisfaction in our roles in its evolution.

Lessons Learned

The hospitalist model of practice didn’t have a single inventor or place of origin, and anyone involved in starting a practice in the 1980s or before should be proud to have invented their practice when no blueprint existed. Creative thinking and openness to a new way of doing things were critical in developing the first hospitalist practices. They also are useful traits in trying to improve modern hospitalist practices or other segments of our healthcare system.

Like many new developments in medicine, the economic effects of our practice—lower hospital cost per case—became apparent, especially to Chuck, before data regarding quality surfaced. I wish we had gotten more serious early on about capturing whatever quality data might have been available—clearly less than what is available today—and those in new healthcare endeavors today should try to measure quality at the outset. Unlike the 1980s, the current marketplace will help ensure that happens.

Coda

There is one other really cool thing about Chuck’s email at the beginning of this column: those three exclamation points! Chuck is typically laconic and understated, and not given to such displays of emotion, but there are few things that generate more enthusiasm than a parent sharing news of a child’s success.

So, Ben, as you start med school next year, I wish you the best. You can be sure I’ll be asking for updates about your progress. The most important thing is that you find a life and career that engages you to do good work for others and provides satisfaction. And whatever you choose to do after med school, I know you’ll continue to make your parents proud.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is course co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.

Patient Transfers

Hospitalist billing depends on several factors. Know your role and avoid common mistakes Patient transfers can occur for many reasons: advanced technological services required, health insurance coverage, or a change in the level of care, to name a few. Patient care that is provided in the acute-care setting does not always terminate with discharge to home. Frequently, hospitalists are involved in patient transfers to another location to receive additional services: intrafacility (a different unit or related facility within the same physical plant) or interfacility (geographically separate facilities). The hospitalist must identify his or her role in the transfer and the patient’s new environment.

Physician billing in the transferred setting depends upon several factors:¹

• Shared or merged medical record;
• The attending of record in each setting;
• The requirements for care rendered by the hospitalist in each setting; and
• Service dates.

Intrafacility Initial Service

Let’s examine a common example: A hospitalist serves as the “attending of record” in an inpatient hospital where acute care is required for an 83-year-old female with hypertension and diabetes who sustained a left hip fracture. The hospitalist plans to discharge the patient to the rehabilitation unit. After transfer, the rehabilitation physician becomes the attending of record, and the hospitalist might be asked to provide ongoing care for the patient’s hypertension and diabetes.

What should the hospitalist report for the initial post-transfer service? The typical options to consider are:²

• Inpatient consultation (99251-99255);
• Initial hospital care (99221-99223); and
• Subsequent hospital care (99231-99233).

Report a consultation only if the rehab attending requests an opinion or advice for an unrelated, new condition instead of previously treated conditions, and the requesting physician’s intent is for opinion or advice on management options rather than the a priori intent for the hospitalist to assume the patient’s medical care. If these requirements are met, the hospitalist may report an inpatient consultation code (99251-99255). Alternatively, if the intent or need represents a continuity of medical care provided during the acute episode of care, report the most appropriate subsequent hospital care code (99231-99233) for the hospitalist’s initial rehab visit and all follow-up services.

Initial hospital care (99221-99223) codes can only be reported for Medicare beneficiaries in place of consultation codes (99251-99255), as Medicare ceased to reimburse consultation codes.³ Most other payors who do not recognize consultation services only allow one initial hospital care code per hospitalization, reserved for the attending of record.

Interfacility Initial Service

Hospitalist groups provide patient care and coverage in many different types of facilities. Confusion often arises when the “attending of record” during acute care and the “subacute” setting (e.g. long-term acute-care hospital) are two different hospitalists from the same group practice. The hospitalist receiving the patient in the transfer facility may decide to report subsequent hospital care (99231-99233), because the group has been providing ongoing care to this patient. In this scenario, the hospitalist group could be losing revenue if an admission service (99221-99223) was not reported.

An initial hospital care service (99221-99223) is permitted when the transfer is between:

• Different hospitals;
• Different facilities under common ownership which do not have merged records; or
• Between the acute-care hospital and a PPS (prospective payment system)-exempt unit within the same hospital when there are no merged records (e.g. Medicare Part A-covered inpatient care in psychiatric, rehabilitation, critical access, and long-term care hospitals).⁴

In all other transfer circumstances not meeting the elements noted above, the physician should bill only the appropriate level of subsequent hospital care (99231-99233) for the date of transfer.¹ Do not equate “merged records” to commonly accessible charts via an electronic medical record system or an electronic storage system. If the medical record for the patient’s acute stay is “closed” and the patient is given a separate medical record and registration for the stay in the transferred facility, consider the transfer stay as a separate admission.

Billing Two Services on Day of Transfer

Whether the transfer is classified as intrafacility or interfacility, an individual hospitalist or two separate hospitalists from the same group practice may provide the acute-care discharge and the transfer admission. A hospital discharge day management service (99238-99239) and an initial hospital care service (99221-99223) can only be reported if they do not occur on the same day.¹ Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician; if more than one evaluation and management (face to face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported.⁵

The Exception

CMS will allow a single hospitalist or two hospitalists from the same group practice to report a discharge day management service on the same day as an admission service. When they are billed by the same physician or group with the same date of service, contractors are instructed to pay the hospital discharge day management code (99238-99239) in addition to a nursing facility admission code (99304-99306).⁶

Conversely, if the patient is admitted to a hospital (99221-99223) following a nursing facility discharge (99315-99316) on the same date by the same physician/group, insurers will only reimburse the initial hospital care code. Payment for the initial hospital care service includes all work performed by the physician/group in all sites of service on that date.

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

References available online at the-hospitalist.org

ICD-10 Update

On Sept. 5, 2012, the Centers for Medicare & Medicaid Services (CMS) published the final rule for Administration Simplification, which included a compliance date change for the International Classification of Diseases, 10th Edition (ICD-10-CM and ICD-10-PCS), Medical Data Code Sets:⁷

“According to a recent survey conducted by the CMS, up to one-quarter of healthcare providers believe they will not be ready for an October 1, 2013, compliance date. While the survey found no significant differences among practice settings regarding the likelihood of achieving compliance before the deadline, based on recent industry feedback we believe that larger healthcare plans and providers generally are more prepared than smaller entities. The uncertainty about provider readiness is confirmed in another recent readiness survey in which nearly 50 percent of the 2,140 provider respondents did not know when they would complete their impact assessment of the ICD-10 transition. By delaying the compliance date of ICD-10 from October 1, 2013, to October 1, 2014, we are allowing more time for covered entities to prepare for the transition to ICD-10 and to conduct thorough testing. By allowing more time to prepare, covered entities may be able to avoid costly obstacles that would otherwise emerge while in production.”⁷

Although providers have gained a year to adopt ICD-10, this should not deter progress toward the 2014 goal, with hopefulness that additional rulings will be made to further stall full implementation.

Patient Transfers

Hospitalist billing depends on several factors. Know your role and avoid common mistakes Patient transfers can occur for many reasons: advanced technological services required, health insurance coverage, or a change in the level of care, to name a few. Patient care that is provided in the acute-care setting does not always terminate with discharge to home. Frequently, hospitalists are involved in patient transfers to another location to receive additional services: intrafacility (a different unit or related facility within the same physical plant) or interfacility (geographically separate facilities). The hospitalist must identify his or her role in the transfer and the patient’s new environment.

Physician billing in the transferred setting depends upon several factors:¹

• Shared or merged medical record;
• The attending of record in each setting;
• The requirements for care rendered by the hospitalist in each setting; and
• Service dates.

Intrafacility Initial Service

Let’s examine a common example: A hospitalist serves as the “attending of record” in an inpatient hospital where acute care is required for an 83-year-old female with hypertension and diabetes who sustained a left hip fracture. The hospitalist plans to discharge the patient to the rehabilitation unit. After transfer, the rehabilitation physician becomes the attending of record, and the hospitalist might be asked to provide ongoing care for the patient’s hypertension and diabetes.

What should the hospitalist report for the initial post-transfer service? The typical options to consider are:²

• Inpatient consultation (99251-99255);
• Initial hospital care (99221-99223); and
• Subsequent hospital care (99231-99233).

Report a consultation only if the rehab attending requests an opinion or advice for an unrelated, new condition instead of previously treated conditions, and the requesting physician’s intent is for opinion or advice on management options rather than the a priori intent for the hospitalist to assume the patient’s medical care. If these requirements are met, the hospitalist may report an inpatient consultation code (99251-99255). Alternatively, if the intent or need represents a continuity of medical care provided during the acute episode of care, report the most appropriate subsequent hospital care code (99231-99233) for the hospitalist’s initial rehab visit and all follow-up services.

Initial hospital care (99221-99223) codes can only be reported for Medicare beneficiaries in place of consultation codes (99251-99255), as Medicare ceased to reimburse consultation codes.³ Most other payors who do not recognize consultation services only allow one initial hospital care code per hospitalization, reserved for the attending of record.

Interfacility Initial Service

Hospitalist groups provide patient care and coverage in many different types of facilities. Confusion often arises when the “attending of record” during acute care and the “subacute” setting (e.g. long-term acute-care hospital) are two different hospitalists from the same group practice. The hospitalist receiving the patient in the transfer facility may decide to report subsequent hospital care (99231-99233), because the group has been providing ongoing care to this patient. In this scenario, the hospitalist group could be losing revenue if an admission service (99221-99223) was not reported.

An initial hospital care service (99221-99223) is permitted when the transfer is between:

• Different hospitals;
• Different facilities under common ownership which do not have merged records; or
• Between the acute-care hospital and a PPS (prospective payment system)-exempt unit within the same hospital when there are no merged records (e.g. Medicare Part A-covered inpatient care in psychiatric, rehabilitation, critical access, and long-term care hospitals).⁴

In all other transfer circumstances not meeting the elements noted above, the physician should bill only the appropriate level of subsequent hospital care (99231-99233) for the date of transfer.¹ Do not equate “merged records” to commonly accessible charts via an electronic medical record system or an electronic storage system. If the medical record for the patient’s acute stay is “closed” and the patient is given a separate medical record and registration for the stay in the transferred facility, consider the transfer stay as a separate admission.

Billing Two Services on Day of Transfer

Whether the transfer is classified as intrafacility or interfacility, an individual hospitalist or two separate hospitalists from the same group practice may provide the acute-care discharge and the transfer admission. A hospital discharge day management service (99238-99239) and an initial hospital care service (99221-99223) can only be reported if they do not occur on the same day.¹ Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician; if more than one evaluation and management (face to face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported.⁵

The Exception

CMS will allow a single hospitalist or two hospitalists from the same group practice to report a discharge day management service on the same day as an admission service. When they are billed by the same physician or group with the same date of service, contractors are instructed to pay the hospital discharge day management code (99238-99239) in addition to a nursing facility admission code (99304-99306).⁶

Conversely, if the patient is admitted to a hospital (99221-99223) following a nursing facility discharge (99315-99316) on the same date by the same physician/group, insurers will only reimburse the initial hospital care code. Payment for the initial hospital care service includes all work performed by the physician/group in all sites of service on that date.

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

References available online at the-hospitalist.org

ICD-10 Update

On Sept. 5, 2012, the Centers for Medicare & Medicaid Services (CMS) published the final rule for Administration Simplification, which included a compliance date change for the International Classification of Diseases, 10th Edition (ICD-10-CM and ICD-10-PCS), Medical Data Code Sets:⁷

“According to a recent survey conducted by the CMS, up to one-quarter of healthcare providers believe they will not be ready for an October 1, 2013, compliance date. While the survey found no significant differences among practice settings regarding the likelihood of achieving compliance before the deadline, based on recent industry feedback we believe that larger healthcare plans and providers generally are more prepared than smaller entities. The uncertainty about provider readiness is confirmed in another recent readiness survey in which nearly 50 percent of the 2,140 provider respondents did not know when they would complete their impact assessment of the ICD-10 transition. By delaying the compliance date of ICD-10 from October 1, 2013, to October 1, 2014, we are allowing more time for covered entities to prepare for the transition to ICD-10 and to conduct thorough testing. By allowing more time to prepare, covered entities may be able to avoid costly obstacles that would otherwise emerge while in production.”⁷

Although providers have gained a year to adopt ICD-10, this should not deter progress toward the 2014 goal, with hopefulness that additional rulings will be made to further stall full implementation.

Patient Transfers

Hospitalist billing depends on several factors. Know your role and avoid common mistakes Patient transfers can occur for many reasons: advanced technological services required, health insurance coverage, or a change in the level of care, to name a few. Patient care that is provided in the acute-care setting does not always terminate with discharge to home. Frequently, hospitalists are involved in patient transfers to another location to receive additional services: intrafacility (a different unit or related facility within the same physical plant) or interfacility (geographically separate facilities). The hospitalist must identify his or her role in the transfer and the patient’s new environment.

Physician billing in the transferred setting depends upon several factors:¹

• Shared or merged medical record;
• The attending of record in each setting;
• The requirements for care rendered by the hospitalist in each setting; and
• Service dates.

Intrafacility Initial Service

Let’s examine a common example: A hospitalist serves as the “attending of record” in an inpatient hospital where acute care is required for an 83-year-old female with hypertension and diabetes who sustained a left hip fracture. The hospitalist plans to discharge the patient to the rehabilitation unit. After transfer, the rehabilitation physician becomes the attending of record, and the hospitalist might be asked to provide ongoing care for the patient’s hypertension and diabetes.

What should the hospitalist report for the initial post-transfer service? The typical options to consider are:²

• Inpatient consultation (99251-99255);
• Initial hospital care (99221-99223); and
• Subsequent hospital care (99231-99233).

Report a consultation only if the rehab attending requests an opinion or advice for an unrelated, new condition instead of previously treated conditions, and the requesting physician’s intent is for opinion or advice on management options rather than the a priori intent for the hospitalist to assume the patient’s medical care. If these requirements are met, the hospitalist may report an inpatient consultation code (99251-99255). Alternatively, if the intent or need represents a continuity of medical care provided during the acute episode of care, report the most appropriate subsequent hospital care code (99231-99233) for the hospitalist’s initial rehab visit and all follow-up services.

Initial hospital care (99221-99223) codes can only be reported for Medicare beneficiaries in place of consultation codes (99251-99255), as Medicare ceased to reimburse consultation codes.³ Most other payors who do not recognize consultation services only allow one initial hospital care code per hospitalization, reserved for the attending of record.

Interfacility Initial Service

Hospitalist groups provide patient care and coverage in many different types of facilities. Confusion often arises when the “attending of record” during acute care and the “subacute” setting (e.g. long-term acute-care hospital) are two different hospitalists from the same group practice. The hospitalist receiving the patient in the transfer facility may decide to report subsequent hospital care (99231-99233), because the group has been providing ongoing care to this patient. In this scenario, the hospitalist group could be losing revenue if an admission service (99221-99223) was not reported.

An initial hospital care service (99221-99223) is permitted when the transfer is between:

• Different hospitals;
• Different facilities under common ownership which do not have merged records; or
• Between the acute-care hospital and a PPS (prospective payment system)-exempt unit within the same hospital when there are no merged records (e.g. Medicare Part A-covered inpatient care in psychiatric, rehabilitation, critical access, and long-term care hospitals).⁴

In all other transfer circumstances not meeting the elements noted above, the physician should bill only the appropriate level of subsequent hospital care (99231-99233) for the date of transfer.¹ Do not equate “merged records” to commonly accessible charts via an electronic medical record system or an electronic storage system. If the medical record for the patient’s acute stay is “closed” and the patient is given a separate medical record and registration for the stay in the transferred facility, consider the transfer stay as a separate admission.

Billing Two Services on Day of Transfer

Whether the transfer is classified as intrafacility or interfacility, an individual hospitalist or two separate hospitalists from the same group practice may provide the acute-care discharge and the transfer admission. A hospital discharge day management service (99238-99239) and an initial hospital care service (99221-99223) can only be reported if they do not occur on the same day.¹ Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician; if more than one evaluation and management (face to face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported.⁵

The Exception

CMS will allow a single hospitalist or two hospitalists from the same group practice to report a discharge day management service on the same day as an admission service. When they are billed by the same physician or group with the same date of service, contractors are instructed to pay the hospital discharge day management code (99238-99239) in addition to a nursing facility admission code (99304-99306).⁶

Conversely, if the patient is admitted to a hospital (99221-99223) following a nursing facility discharge (99315-99316) on the same date by the same physician/group, insurers will only reimburse the initial hospital care code. Payment for the initial hospital care service includes all work performed by the physician/group in all sites of service on that date.

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

References available online at the-hospitalist.org

ICD-10 Update

On Sept. 5, 2012, the Centers for Medicare & Medicaid Services (CMS) published the final rule for Administration Simplification, which included a compliance date change for the International Classification of Diseases, 10th Edition (ICD-10-CM and ICD-10-PCS), Medical Data Code Sets:⁷

“According to a recent survey conducted by the CMS, up to one-quarter of healthcare providers believe they will not be ready for an October 1, 2013, compliance date. While the survey found no significant differences among practice settings regarding the likelihood of achieving compliance before the deadline, based on recent industry feedback we believe that larger healthcare plans and providers generally are more prepared than smaller entities. The uncertainty about provider readiness is confirmed in another recent readiness survey in which nearly 50 percent of the 2,140 provider respondents did not know when they would complete their impact assessment of the ICD-10 transition. By delaying the compliance date of ICD-10 from October 1, 2013, to October 1, 2014, we are allowing more time for covered entities to prepare for the transition to ICD-10 and to conduct thorough testing. By allowing more time to prepare, covered entities may be able to avoid costly obstacles that would otherwise emerge while in production.”⁷

Although providers have gained a year to adopt ICD-10, this should not deter progress toward the 2014 goal, with hopefulness that additional rulings will be made to further stall full implementation.

Dr. Hospitalist

Position Paper Did Not Address Family Practice Physicians in ICU

I just finished reading “The Critical-Care Debate” article in The Hospitalist’s October issue. I was quite interested in getting further follow-up and comments regarding family practice physicians’ role in critical care. Now that some hospitalist programs are utilized as “intensivists,” what are SHM and the Society of Critical Care Medicine’s (SCCM) opinions of family practitioners who are hospitalists acting in this manner? The TH article says that internal-medicine programs are insufficient for preparing internists; what are SHM and SCCM’s positions and opinions of family practice physicians being utilized as intensivists?

—Ray Nowaczyk, DO

Dr. Hospitalist responds:

Boy, and we thought this issue was politically charged before you asked that question. From my reading of the position paper (J Hosp Med. 2012;7:359-364) cited in the article, the role of family practice physicians is only alluded to, and not addressed except by its absence. The main thrust of the paper focuses specifically on physicians trained in internal medicine (IM) and how they could become “qualified” to provide ICU care. A few items stand out:

1. The baseline assumption is that these would be IM-trained physicians, not family practice physicians.
2. The requirements to entry wouldinclude: a) completion of IM residency; b) three years’ clinical practice as a hospitalist; and c) enrollment in the ABIM Focused Practice in Hospital Medicine Maintenance of Certification process, which, by definition, requires board certification in internal medicine.

Judging by the vocal backlash from the American College of Chest Physicians (ACCP), I imagine that even getting consensus on the points above required some fairly heavy lifting. Addressing the issue of family practitioners in HM likely was not a topic they felt could gain traction

You are absolutely correct, though, in that plenty of family practitioners practice full time as adult hospitalists (and are doing a fine job). As the paper notes, it is estimated that 6% to 8% of all hospitalists are familypractice- trained. Unfortunately, there is very little objective documentation that will allow them to demonstrate their clinical quality other than direct clinical practice or observation. There is no formal “bridge” to cross for a family practice physician wanting to receive certification in hospital medicine; this currently can only happen through ABIM.

At the same time, I do not believe that the absence of formal certification disqualifies any family practitioner from practicing quality medicine in the hospital. In fact, in my market, there are some fantastic family practice hospitalists who have been in practice in a busy, urban, Level I hospital for more than 10 years. They clearly have the clinical experience and skills that would vastly outweigh those of almost any new graduate of an internal-medicine program. Can they prove it? Not today.

I think it’s a similar discussion with IM-trained hospitalists providing ICU care. I have colleagues who actively seek to accept and care for ICU patients when it comes time for admissions, and these physicians spend much more time in direct patient care in the ICU than even some of our intensivists. Can they prove their skills? Not today. However, as noted in the Leapfrog data, at this point, only 4% of ICUs have 24/7 dedicated intensivists, so who are we kidding? We need hospitalists to provide competent ICU care. Whether we provide a pathway for objective recognition or not, it is still going to happen. It sure would be nice if it happened in a sensible way with input from the stakeholders—just as was suggested in the position paper.

Here’s a little anecdote: Many years ago, there was an ortho PA (we’ll call him Jimmy John) in our hospital, but when you called his pager number, which he also gave out routinely to patients, the message said, “You’ve reached the pager of Doctor John.” He was no doctor. Well, one of us finally asked him about it, and he replied, with a straight face: “Oh, I used to be a vet.” OK.

The point is, we all need to recognize our own skills and limitations and be able to communicate those same skills and limitations to others, especially to patients, honestly. Since honesty has its limits, then independent objective measurement is a useful adjunct. Just look at your office walls.

Dr. Hospitalist

Position Paper Did Not Address Family Practice Physicians in ICU

I just finished reading “The Critical-Care Debate” article in The Hospitalist’s October issue. I was quite interested in getting further follow-up and comments regarding family practice physicians’ role in critical care. Now that some hospitalist programs are utilized as “intensivists,” what are SHM and the Society of Critical Care Medicine’s (SCCM) opinions of family practitioners who are hospitalists acting in this manner? The TH article says that internal-medicine programs are insufficient for preparing internists; what are SHM and SCCM’s positions and opinions of family practice physicians being utilized as intensivists?

—Ray Nowaczyk, DO

Dr. Hospitalist responds:

Boy, and we thought this issue was politically charged before you asked that question. From my reading of the position paper (J Hosp Med. 2012;7:359-364) cited in the article, the role of family practice physicians is only alluded to, and not addressed except by its absence. The main thrust of the paper focuses specifically on physicians trained in internal medicine (IM) and how they could become “qualified” to provide ICU care. A few items stand out:

1. The baseline assumption is that these would be IM-trained physicians, not family practice physicians.
2. The requirements to entry wouldinclude: a) completion of IM residency; b) three years’ clinical practice as a hospitalist; and c) enrollment in the ABIM Focused Practice in Hospital Medicine Maintenance of Certification process, which, by definition, requires board certification in internal medicine.

Judging by the vocal backlash from the American College of Chest Physicians (ACCP), I imagine that even getting consensus on the points above required some fairly heavy lifting. Addressing the issue of family practitioners in HM likely was not a topic they felt could gain traction

You are absolutely correct, though, in that plenty of family practitioners practice full time as adult hospitalists (and are doing a fine job). As the paper notes, it is estimated that 6% to 8% of all hospitalists are familypractice- trained. Unfortunately, there is very little objective documentation that will allow them to demonstrate their clinical quality other than direct clinical practice or observation. There is no formal “bridge” to cross for a family practice physician wanting to receive certification in hospital medicine; this currently can only happen through ABIM.

At the same time, I do not believe that the absence of formal certification disqualifies any family practitioner from practicing quality medicine in the hospital. In fact, in my market, there are some fantastic family practice hospitalists who have been in practice in a busy, urban, Level I hospital for more than 10 years. They clearly have the clinical experience and skills that would vastly outweigh those of almost any new graduate of an internal-medicine program. Can they prove it? Not today.

I think it’s a similar discussion with IM-trained hospitalists providing ICU care. I have colleagues who actively seek to accept and care for ICU patients when it comes time for admissions, and these physicians spend much more time in direct patient care in the ICU than even some of our intensivists. Can they prove their skills? Not today. However, as noted in the Leapfrog data, at this point, only 4% of ICUs have 24/7 dedicated intensivists, so who are we kidding? We need hospitalists to provide competent ICU care. Whether we provide a pathway for objective recognition or not, it is still going to happen. It sure would be nice if it happened in a sensible way with input from the stakeholders—just as was suggested in the position paper.

Here’s a little anecdote: Many years ago, there was an ortho PA (we’ll call him Jimmy John) in our hospital, but when you called his pager number, which he also gave out routinely to patients, the message said, “You’ve reached the pager of Doctor John.” He was no doctor. Well, one of us finally asked him about it, and he replied, with a straight face: “Oh, I used to be a vet.” OK.

The point is, we all need to recognize our own skills and limitations and be able to communicate those same skills and limitations to others, especially to patients, honestly. Since honesty has its limits, then independent objective measurement is a useful adjunct. Just look at your office walls.

Dr. Hospitalist

Position Paper Did Not Address Family Practice Physicians in ICU

I just finished reading “The Critical-Care Debate” article in The Hospitalist’s October issue. I was quite interested in getting further follow-up and comments regarding family practice physicians’ role in critical care. Now that some hospitalist programs are utilized as “intensivists,” what are SHM and the Society of Critical Care Medicine’s (SCCM) opinions of family practitioners who are hospitalists acting in this manner? The TH article says that internal-medicine programs are insufficient for preparing internists; what are SHM and SCCM’s positions and opinions of family practice physicians being utilized as intensivists?

—Ray Nowaczyk, DO

Dr. Hospitalist responds:

Boy, and we thought this issue was politically charged before you asked that question. From my reading of the position paper (J Hosp Med. 2012;7:359-364) cited in the article, the role of family practice physicians is only alluded to, and not addressed except by its absence. The main thrust of the paper focuses specifically on physicians trained in internal medicine (IM) and how they could become “qualified” to provide ICU care. A few items stand out:

1. The baseline assumption is that these would be IM-trained physicians, not family practice physicians.
2. The requirements to entry wouldinclude: a) completion of IM residency; b) three years’ clinical practice as a hospitalist; and c) enrollment in the ABIM Focused Practice in Hospital Medicine Maintenance of Certification process, which, by definition, requires board certification in internal medicine.

Judging by the vocal backlash from the American College of Chest Physicians (ACCP), I imagine that even getting consensus on the points above required some fairly heavy lifting. Addressing the issue of family practitioners in HM likely was not a topic they felt could gain traction

You are absolutely correct, though, in that plenty of family practitioners practice full time as adult hospitalists (and are doing a fine job). As the paper notes, it is estimated that 6% to 8% of all hospitalists are familypractice- trained. Unfortunately, there is very little objective documentation that will allow them to demonstrate their clinical quality other than direct clinical practice or observation. There is no formal “bridge” to cross for a family practice physician wanting to receive certification in hospital medicine; this currently can only happen through ABIM.

At the same time, I do not believe that the absence of formal certification disqualifies any family practitioner from practicing quality medicine in the hospital. In fact, in my market, there are some fantastic family practice hospitalists who have been in practice in a busy, urban, Level I hospital for more than 10 years. They clearly have the clinical experience and skills that would vastly outweigh those of almost any new graduate of an internal-medicine program. Can they prove it? Not today.

I think it’s a similar discussion with IM-trained hospitalists providing ICU care. I have colleagues who actively seek to accept and care for ICU patients when it comes time for admissions, and these physicians spend much more time in direct patient care in the ICU than even some of our intensivists. Can they prove their skills? Not today. However, as noted in the Leapfrog data, at this point, only 4% of ICUs have 24/7 dedicated intensivists, so who are we kidding? We need hospitalists to provide competent ICU care. Whether we provide a pathway for objective recognition or not, it is still going to happen. It sure would be nice if it happened in a sensible way with input from the stakeholders—just as was suggested in the position paper.

Here’s a little anecdote: Many years ago, there was an ortho PA (we’ll call him Jimmy John) in our hospital, but when you called his pager number, which he also gave out routinely to patients, the message said, “You’ve reached the pager of Doctor John.” He was no doctor. Well, one of us finally asked him about it, and he replied, with a straight face: “Oh, I used to be a vet.” OK.

The point is, we all need to recognize our own skills and limitations and be able to communicate those same skills and limitations to others, especially to patients, honestly. Since honesty has its limits, then independent objective measurement is a useful adjunct. Just look at your office walls.

An increasing number of hospitalists are pursuing part-time schedules to cater to lifestyle demands and personal desires. According to a 2010 survey conducted by the American Medical Group Management Association and Cejka Search, 21% of physicians in the U.S. are working part time, compared with only 13% in 2005.

Among those part-time physicians, the fastest-growing segments are men approaching retirement and women in the early to middle stages of their careers. Senior physicians who are tired of the commitment that comes with full-time employment increasingly are opting for part-time employment as a transition into retirement. Physicians with young children are seeking part-time employment to be more active in child-rearing.

The medical community generally has welcomed the opportunity to incorporate part-time physicians into hospital settings as a way to maintain female physicians, senior physicians, and physicians in specialties experiencing shortages. Physicians who are retained on a part-time basis should be cognizant of the following areas of the physician’s employment or independent contractor agreement:

• Independent contractor or employee status;
• Compensation;
• Benefits;
• Professional liability (malpractice) insurance; and
• Restrictive covenants.

Independent Contractor vs. Employee

Oftentimes, physicians assume that just because he or she is working part time, he or she is an independent contractor. That is an inaccurate assumption. The amount of time a physician works is not the determining factor as to whether someone is an employee or an independent contractor of the practice or hospital. Whether a physician is an employee or an independent contractor is a distinction with real consequences for tax purposes and protections under federal and state labor and employment laws.

Generally, labor and employment laws provide protections for employees, but these protections do not extend to independent contractors. With regard to taxes, if a hospitalist is an employee, the employer is required to withhold income, Social Security, and Medicare taxes, and pay unemployment tax on wages paid to the hospitalist. Conversely, if a hospitalist is an independent contractor, the practice or hospital will not withhold or pay taxes on payments to the hospitalist; rather, the individual hospitalist will be responsible for making those payments to the IRS and state tax authorities. It is imperative that the contract clearly indicates whether the hospitalist is an employee or an independent contractor, as well as the corresponding responsibilities of the parties.

Compensation and Benefits

Partial compensation for part-time work is logical, but determining a fair and competitive compensation package is not always as straightforward when it comes to part-timers. There are two general models that practices and hospitals use to determine compensation for hospitalists working part time. First, the physician may be paid a percentage of a full-time physician’s salary, based on the number of hours worked. Second, the physician may receive a per diem rate or an hourly rate. As with full-time physicians, there are various ways to formulate a part-time physician’s compensation, and the method used should be explicitly outlined in the physician’s employment or independent contractor agreement.

Benefit plans and arrangements (such as health, dental, vision, retirement plan, pension plan, disability coverage, life insurance, etc.) frequently are provided to employees and infrequently provided to independent contractors. Whether a physician who is working part time will receive benefits will vary from employer to employer. A threshold issue, however, is whether a part-time worker is even eligible to receive certain benefits. Many health, dental, and vision plans require employees to work a minimum of 30 hours a week on a regular basis, thus excluding part-time employees who work fewer hours. For retirement and pension plans, employees typically must work a minimum of 1,000 hours per year to be eligible to participate. Even if a hospitalist’s employment agreement provides that the hospitalist may receive benefits from the employer, the agreement may also provide that such a provision is subject to the terms and conditions of the particular benefit plans or arrangements.

Professional Liability (Malpractice) Insurance

While some practices or hospitals pay for a part-time physician’s malpractice insurance premiums, many shift some or all of these costs to the physician. Many insurance providers offer malpractice plans for physicians practicing part time, with reduced premiums and reduced coverage.

When negotiating a compensation package, payment for malpractice insurance should be considered. A physician also must be aware of what is excluded from coverage. For example, if a physician works part time with Hospital A and part time with Hospital B, and Hospital A provides malpractice coverage for the physician, it cannot be assumed that such coverage will cover the physician’s work with Hospital B. In this case, the physician may need a separate policy for work performed through Hospital B.

Restrictive Covenants

Although a physician might only be employed on a part-time basis, the employer might nevertheless want to protect itself by including restrictive covenants (i.e. noncompetition and nonsolicitation clauses) in the physician’s employment agreement. A part-time physician must be careful that the restrictive covenants do not jeopardize their other career objectives. For example, in the example described above with the physician working part time for both Hospital A and Hospital B, a noncompetition clause in the physician’s employment agreement with Hospital A could prohibit the physician from working at another hospital, including Hospital B.

Retaining part-time hospitalists is an increasingly attractive option for physician practices and hospitals, and part-time work is an increasingly attractive option for physicians. The items described above are just a few of the provisions that are unique to the part-time physician relationship that should be reflected in the physician’s employment or independent contractor agreement.

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

An increasing number of hospitalists are pursuing part-time schedules to cater to lifestyle demands and personal desires. According to a 2010 survey conducted by the American Medical Group Management Association and Cejka Search, 21% of physicians in the U.S. are working part time, compared with only 13% in 2005.

Among those part-time physicians, the fastest-growing segments are men approaching retirement and women in the early to middle stages of their careers. Senior physicians who are tired of the commitment that comes with full-time employment increasingly are opting for part-time employment as a transition into retirement. Physicians with young children are seeking part-time employment to be more active in child-rearing.

The medical community generally has welcomed the opportunity to incorporate part-time physicians into hospital settings as a way to maintain female physicians, senior physicians, and physicians in specialties experiencing shortages. Physicians who are retained on a part-time basis should be cognizant of the following areas of the physician’s employment or independent contractor agreement:

• Independent contractor or employee status;
• Compensation;
• Benefits;
• Professional liability (malpractice) insurance; and
• Restrictive covenants.

Independent Contractor vs. Employee

Oftentimes, physicians assume that just because he or she is working part time, he or she is an independent contractor. That is an inaccurate assumption. The amount of time a physician works is not the determining factor as to whether someone is an employee or an independent contractor of the practice or hospital. Whether a physician is an employee or an independent contractor is a distinction with real consequences for tax purposes and protections under federal and state labor and employment laws.

Generally, labor and employment laws provide protections for employees, but these protections do not extend to independent contractors. With regard to taxes, if a hospitalist is an employee, the employer is required to withhold income, Social Security, and Medicare taxes, and pay unemployment tax on wages paid to the hospitalist. Conversely, if a hospitalist is an independent contractor, the practice or hospital will not withhold or pay taxes on payments to the hospitalist; rather, the individual hospitalist will be responsible for making those payments to the IRS and state tax authorities. It is imperative that the contract clearly indicates whether the hospitalist is an employee or an independent contractor, as well as the corresponding responsibilities of the parties.

Compensation and Benefits

Partial compensation for part-time work is logical, but determining a fair and competitive compensation package is not always as straightforward when it comes to part-timers. There are two general models that practices and hospitals use to determine compensation for hospitalists working part time. First, the physician may be paid a percentage of a full-time physician’s salary, based on the number of hours worked. Second, the physician may receive a per diem rate or an hourly rate. As with full-time physicians, there are various ways to formulate a part-time physician’s compensation, and the method used should be explicitly outlined in the physician’s employment or independent contractor agreement.

Benefit plans and arrangements (such as health, dental, vision, retirement plan, pension plan, disability coverage, life insurance, etc.) frequently are provided to employees and infrequently provided to independent contractors. Whether a physician who is working part time will receive benefits will vary from employer to employer. A threshold issue, however, is whether a part-time worker is even eligible to receive certain benefits. Many health, dental, and vision plans require employees to work a minimum of 30 hours a week on a regular basis, thus excluding part-time employees who work fewer hours. For retirement and pension plans, employees typically must work a minimum of 1,000 hours per year to be eligible to participate. Even if a hospitalist’s employment agreement provides that the hospitalist may receive benefits from the employer, the agreement may also provide that such a provision is subject to the terms and conditions of the particular benefit plans or arrangements.

Professional Liability (Malpractice) Insurance

While some practices or hospitals pay for a part-time physician’s malpractice insurance premiums, many shift some or all of these costs to the physician. Many insurance providers offer malpractice plans for physicians practicing part time, with reduced premiums and reduced coverage.

When negotiating a compensation package, payment for malpractice insurance should be considered. A physician also must be aware of what is excluded from coverage. For example, if a physician works part time with Hospital A and part time with Hospital B, and Hospital A provides malpractice coverage for the physician, it cannot be assumed that such coverage will cover the physician’s work with Hospital B. In this case, the physician may need a separate policy for work performed through Hospital B.

Restrictive Covenants

Although a physician might only be employed on a part-time basis, the employer might nevertheless want to protect itself by including restrictive covenants (i.e. noncompetition and nonsolicitation clauses) in the physician’s employment agreement. A part-time physician must be careful that the restrictive covenants do not jeopardize their other career objectives. For example, in the example described above with the physician working part time for both Hospital A and Hospital B, a noncompetition clause in the physician’s employment agreement with Hospital A could prohibit the physician from working at another hospital, including Hospital B.

Retaining part-time hospitalists is an increasingly attractive option for physician practices and hospitals, and part-time work is an increasingly attractive option for physicians. The items described above are just a few of the provisions that are unique to the part-time physician relationship that should be reflected in the physician’s employment or independent contractor agreement.

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

An increasing number of hospitalists are pursuing part-time schedules to cater to lifestyle demands and personal desires. According to a 2010 survey conducted by the American Medical Group Management Association and Cejka Search, 21% of physicians in the U.S. are working part time, compared with only 13% in 2005.

Among those part-time physicians, the fastest-growing segments are men approaching retirement and women in the early to middle stages of their careers. Senior physicians who are tired of the commitment that comes with full-time employment increasingly are opting for part-time employment as a transition into retirement. Physicians with young children are seeking part-time employment to be more active in child-rearing.

The medical community generally has welcomed the opportunity to incorporate part-time physicians into hospital settings as a way to maintain female physicians, senior physicians, and physicians in specialties experiencing shortages. Physicians who are retained on a part-time basis should be cognizant of the following areas of the physician’s employment or independent contractor agreement:

• Independent contractor or employee status;
• Compensation;
• Benefits;
• Professional liability (malpractice) insurance; and
• Restrictive covenants.

Independent Contractor vs. Employee

Oftentimes, physicians assume that just because he or she is working part time, he or she is an independent contractor. That is an inaccurate assumption. The amount of time a physician works is not the determining factor as to whether someone is an employee or an independent contractor of the practice or hospital. Whether a physician is an employee or an independent contractor is a distinction with real consequences for tax purposes and protections under federal and state labor and employment laws.

Generally, labor and employment laws provide protections for employees, but these protections do not extend to independent contractors. With regard to taxes, if a hospitalist is an employee, the employer is required to withhold income, Social Security, and Medicare taxes, and pay unemployment tax on wages paid to the hospitalist. Conversely, if a hospitalist is an independent contractor, the practice or hospital will not withhold or pay taxes on payments to the hospitalist; rather, the individual hospitalist will be responsible for making those payments to the IRS and state tax authorities. It is imperative that the contract clearly indicates whether the hospitalist is an employee or an independent contractor, as well as the corresponding responsibilities of the parties.

Compensation and Benefits

Partial compensation for part-time work is logical, but determining a fair and competitive compensation package is not always as straightforward when it comes to part-timers. There are two general models that practices and hospitals use to determine compensation for hospitalists working part time. First, the physician may be paid a percentage of a full-time physician’s salary, based on the number of hours worked. Second, the physician may receive a per diem rate or an hourly rate. As with full-time physicians, there are various ways to formulate a part-time physician’s compensation, and the method used should be explicitly outlined in the physician’s employment or independent contractor agreement.

Benefit plans and arrangements (such as health, dental, vision, retirement plan, pension plan, disability coverage, life insurance, etc.) frequently are provided to employees and infrequently provided to independent contractors. Whether a physician who is working part time will receive benefits will vary from employer to employer. A threshold issue, however, is whether a part-time worker is even eligible to receive certain benefits. Many health, dental, and vision plans require employees to work a minimum of 30 hours a week on a regular basis, thus excluding part-time employees who work fewer hours. For retirement and pension plans, employees typically must work a minimum of 1,000 hours per year to be eligible to participate. Even if a hospitalist’s employment agreement provides that the hospitalist may receive benefits from the employer, the agreement may also provide that such a provision is subject to the terms and conditions of the particular benefit plans or arrangements.

Professional Liability (Malpractice) Insurance

While some practices or hospitals pay for a part-time physician’s malpractice insurance premiums, many shift some or all of these costs to the physician. Many insurance providers offer malpractice plans for physicians practicing part time, with reduced premiums and reduced coverage.

When negotiating a compensation package, payment for malpractice insurance should be considered. A physician also must be aware of what is excluded from coverage. For example, if a physician works part time with Hospital A and part time with Hospital B, and Hospital A provides malpractice coverage for the physician, it cannot be assumed that such coverage will cover the physician’s work with Hospital B. In this case, the physician may need a separate policy for work performed through Hospital B.

Restrictive Covenants

Although a physician might only be employed on a part-time basis, the employer might nevertheless want to protect itself by including restrictive covenants (i.e. noncompetition and nonsolicitation clauses) in the physician’s employment agreement. A part-time physician must be careful that the restrictive covenants do not jeopardize their other career objectives. For example, in the example described above with the physician working part time for both Hospital A and Hospital B, a noncompetition clause in the physician’s employment agreement with Hospital A could prohibit the physician from working at another hospital, including Hospital B.

Retaining part-time hospitalists is an increasingly attractive option for physician practices and hospitals, and part-time work is an increasingly attractive option for physicians. The items described above are just a few of the provisions that are unique to the part-time physician relationship that should be reflected in the physician’s employment or independent contractor agreement.

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

Edward Ma, MD, wasn’t sure what he wanted to be when he grew up. As a biology student at the University of Pennsylvania in Philadelphia, he says friends “peer-pressured” him to choose a career in medicine. Once the decision was made and he began his training, he found out he was pretty good at the doctor thing.

“I realized that I like this,” he says. “I told myself, ‘I’m going to go for it.’”

Dr. Ma also realized he had a liking for business, and where better to study business than at Penn’s Wharton School of Business? He hasn’t completed an MBA, but he’s taken post-grad courses focused on healthcare management. And now he’s combining that knowledge with his experiences as a hospitalist and medical director to develop a consulting business.

“That sort of evolved because I sort of have a big mouth. When I see something wrong, or something that could be done better, I tend to vocalize it,” says Dr. Ma, medical director of hospitalist services at 168-bed Brandywine Hospital in Coatesville, Pa. “The biggest opportunity is to really help a hospitalist group realize its potential and its value.”

Dr. Ma joined Team Hospitalist in April 2012. Although his side business is evolving via “word of mouth,” he still spends the majority of his time in the hospital directing a six-member HM group and caring for hospitalized patients.

Question: What do you like most about caring for patients?

Answer: I like the acuity of the care. The acuity of the illness is pretty high for our patients, and you can see very quickly the impact hospitalists can have. A lot of outpatient medicine is preventive care, so usually you don’t have an immediate problem that needs to be fixed, whereas in HM, the patients are acutely ill and there’s an ability to get these patients better—and see a change in their medical condition in a day or two. There’s more immediate gratification in terms of the effort that we put in caring for a patient.

Q: What do you like least?

A: The paperwork. At my hospital, a lot of it is computerized. But there are tons of checklists, tons of quality measures that need to be addressed, which is good. Still, it ends up bogging down our ability to take care of the patient. For example, a patient comes in for pneumonia and you have to make sure that some of their chronic issues (e.g. diabetes) are addressed. Have they had their hemoglobin A1C checked in the last 60 days? Does it really matter right now when we’re taking care of the patient’s pneumonia that we have to address this? Smoking cessation, yes, it’s very important, and we need to address this, but is it really necessary that we do this at this point when a patient is really ill? I think there’s a lot of these government regulations that they want us to take care of sometimes in the acute setting, which sometimes feels awkward or not necessarily time-appropriate.

Q: You say your training as an internist prepared you for a seamless transition to a hospitalist job, but you also think IM training is “doing a disservice to medicine.” How so?

A: Don’t get me wrong, I love hospital medicine. But I think what we really need is more primary-care doctors. This is not just my commentary on hospital medicine, but all subspecialties. I know specifically speaking that we need more outpatient internists, outpatient family physicians. If there are many internists, they’re not going to have as much need for cardiology or GI, or a lot of other subspecialties. There’s enough of a population of internists that would satisfy the need for internists and obviously the need for subspecialties.

Q: What’s the biggest change in HM you’ve witnessed since you started 10 years ago?

A: Our acceptance as a field by the medical community. Other physicians have now come to be very accepting of our role as the primary caretakers of their hospitalized patients.

Q: Do you consider yourself to have an entrepreneurial spirit or are you more of a solutions-oriented physician?

A: I have more of the entrepreneurial spirit. I’ve been talking to a lot of hospitalists, and what I encourage them to do is completely counter to the current healthcare environment. I’ve been encouraging them to say, “Let’s get a bunch of us together and set up our own hospitalist practice and do it in a way that we can have a certain level of autonomy, but also do it in a way that we can collaborate with the hospital, work intimately with them, and get certain guarantees from them. And do it privately, so that we can maintain our autonomy.” I think that’s important because I see the difference between the private practices and the practices that are owned by a health system. People just care so much more when it’s their own practice.

Q: What are the biggest challenges you face as medical director?

A: Getting everyone to work as a team. Everyone has a different schedule, differing values, and priorities. It’s very important that we work as a team because when one person does something, it impacts what somebody else does.

Q: What’s the most important thing to know when starting an HM group or fixing a broken group?

A: For fixing a group, you have to look at the values of the group of doctors. What are the values? What are the objectives? What are the professional goals? What I’ve encountered in HM is a lot of people are just coming in to get a paycheck. They come in, they do their job, and they like to take care of patients. Don’t get me wrong about that, but they like the freedom and the high competition that’s provided by hospital medicine. Oftentimes they come in, they do their jobs very well, they take care of their patients, and then they’re out the door. They don’t really have an interest in building up that practice or building up something for the hospital. We as doctors are all part of a medical community, we’re part of a medical staff, and it’s very important for us to get involved.

Q: Last year, you became president of SHM’s Philadelphia Tri-State Region chapter. What are your goals?

A: I’ve always been involved with the chapter, but I saw it as a good opportunity to network and talk with more hospitalists. I wanted to get their viewpoints on things and bounce ideas. I’m a very vocal person, so when I hear a good idea, I like to spread it amongst other people. And if I see something that someone said was bad and I hear it from enough people, I like to bring it up and discuss with everybody.

Q: What’s the best part of being an SHM member?

A: Getting to interact with a lot of my colleagues. To see what struggles they’re going through, to see that their struggles are very similar to the struggles that my group is going through, that we’re all in the same boat, and that we need to collaborate a little more to make things work. Instead of each practice trying to reinvent the wheel, we can try to work together and build off each other.

Richard Quinn is a freelance writer in New Jersey.

Edward Ma, MD, wasn’t sure what he wanted to be when he grew up. As a biology student at the University of Pennsylvania in Philadelphia, he says friends “peer-pressured” him to choose a career in medicine. Once the decision was made and he began his training, he found out he was pretty good at the doctor thing.

“I realized that I like this,” he says. “I told myself, ‘I’m going to go for it.’”

Dr. Ma also realized he had a liking for business, and where better to study business than at Penn’s Wharton School of Business? He hasn’t completed an MBA, but he’s taken post-grad courses focused on healthcare management. And now he’s combining that knowledge with his experiences as a hospitalist and medical director to develop a consulting business.

“That sort of evolved because I sort of have a big mouth. When I see something wrong, or something that could be done better, I tend to vocalize it,” says Dr. Ma, medical director of hospitalist services at 168-bed Brandywine Hospital in Coatesville, Pa. “The biggest opportunity is to really help a hospitalist group realize its potential and its value.”

Dr. Ma joined Team Hospitalist in April 2012. Although his side business is evolving via “word of mouth,” he still spends the majority of his time in the hospital directing a six-member HM group and caring for hospitalized patients.

Question: What do you like most about caring for patients?

Answer: I like the acuity of the care. The acuity of the illness is pretty high for our patients, and you can see very quickly the impact hospitalists can have. A lot of outpatient medicine is preventive care, so usually you don’t have an immediate problem that needs to be fixed, whereas in HM, the patients are acutely ill and there’s an ability to get these patients better—and see a change in their medical condition in a day or two. There’s more immediate gratification in terms of the effort that we put in caring for a patient.

Q: What do you like least?

A: The paperwork. At my hospital, a lot of it is computerized. But there are tons of checklists, tons of quality measures that need to be addressed, which is good. Still, it ends up bogging down our ability to take care of the patient. For example, a patient comes in for pneumonia and you have to make sure that some of their chronic issues (e.g. diabetes) are addressed. Have they had their hemoglobin A1C checked in the last 60 days? Does it really matter right now when we’re taking care of the patient’s pneumonia that we have to address this? Smoking cessation, yes, it’s very important, and we need to address this, but is it really necessary that we do this at this point when a patient is really ill? I think there’s a lot of these government regulations that they want us to take care of sometimes in the acute setting, which sometimes feels awkward or not necessarily time-appropriate.

Q: You say your training as an internist prepared you for a seamless transition to a hospitalist job, but you also think IM training is “doing a disservice to medicine.” How so?

A: Don’t get me wrong, I love hospital medicine. But I think what we really need is more primary-care doctors. This is not just my commentary on hospital medicine, but all subspecialties. I know specifically speaking that we need more outpatient internists, outpatient family physicians. If there are many internists, they’re not going to have as much need for cardiology or GI, or a lot of other subspecialties. There’s enough of a population of internists that would satisfy the need for internists and obviously the need for subspecialties.

Q: What’s the biggest change in HM you’ve witnessed since you started 10 years ago?

A: Our acceptance as a field by the medical community. Other physicians have now come to be very accepting of our role as the primary caretakers of their hospitalized patients.

Q: Do you consider yourself to have an entrepreneurial spirit or are you more of a solutions-oriented physician?

A: I have more of the entrepreneurial spirit. I’ve been talking to a lot of hospitalists, and what I encourage them to do is completely counter to the current healthcare environment. I’ve been encouraging them to say, “Let’s get a bunch of us together and set up our own hospitalist practice and do it in a way that we can have a certain level of autonomy, but also do it in a way that we can collaborate with the hospital, work intimately with them, and get certain guarantees from them. And do it privately, so that we can maintain our autonomy.” I think that’s important because I see the difference between the private practices and the practices that are owned by a health system. People just care so much more when it’s their own practice.

Q: What are the biggest challenges you face as medical director?

A: Getting everyone to work as a team. Everyone has a different schedule, differing values, and priorities. It’s very important that we work as a team because when one person does something, it impacts what somebody else does.

Q: What’s the most important thing to know when starting an HM group or fixing a broken group?

A: For fixing a group, you have to look at the values of the group of doctors. What are the values? What are the objectives? What are the professional goals? What I’ve encountered in HM is a lot of people are just coming in to get a paycheck. They come in, they do their job, and they like to take care of patients. Don’t get me wrong about that, but they like the freedom and the high competition that’s provided by hospital medicine. Oftentimes they come in, they do their jobs very well, they take care of their patients, and then they’re out the door. They don’t really have an interest in building up that practice or building up something for the hospital. We as doctors are all part of a medical community, we’re part of a medical staff, and it’s very important for us to get involved.

Q: Last year, you became president of SHM’s Philadelphia Tri-State Region chapter. What are your goals?

A: I’ve always been involved with the chapter, but I saw it as a good opportunity to network and talk with more hospitalists. I wanted to get their viewpoints on things and bounce ideas. I’m a very vocal person, so when I hear a good idea, I like to spread it amongst other people. And if I see something that someone said was bad and I hear it from enough people, I like to bring it up and discuss with everybody.

Q: What’s the best part of being an SHM member?

A: Getting to interact with a lot of my colleagues. To see what struggles they’re going through, to see that their struggles are very similar to the struggles that my group is going through, that we’re all in the same boat, and that we need to collaborate a little more to make things work. Instead of each practice trying to reinvent the wheel, we can try to work together and build off each other.

Richard Quinn is a freelance writer in New Jersey.

Edward Ma, MD, wasn’t sure what he wanted to be when he grew up. As a biology student at the University of Pennsylvania in Philadelphia, he says friends “peer-pressured” him to choose a career in medicine. Once the decision was made and he began his training, he found out he was pretty good at the doctor thing.

“I realized that I like this,” he says. “I told myself, ‘I’m going to go for it.’”

Dr. Ma also realized he had a liking for business, and where better to study business than at Penn’s Wharton School of Business? He hasn’t completed an MBA, but he’s taken post-grad courses focused on healthcare management. And now he’s combining that knowledge with his experiences as a hospitalist and medical director to develop a consulting business.

“That sort of evolved because I sort of have a big mouth. When I see something wrong, or something that could be done better, I tend to vocalize it,” says Dr. Ma, medical director of hospitalist services at 168-bed Brandywine Hospital in Coatesville, Pa. “The biggest opportunity is to really help a hospitalist group realize its potential and its value.”

Dr. Ma joined Team Hospitalist in April 2012. Although his side business is evolving via “word of mouth,” he still spends the majority of his time in the hospital directing a six-member HM group and caring for hospitalized patients.

Question: What do you like most about caring for patients?

Answer: I like the acuity of the care. The acuity of the illness is pretty high for our patients, and you can see very quickly the impact hospitalists can have. A lot of outpatient medicine is preventive care, so usually you don’t have an immediate problem that needs to be fixed, whereas in HM, the patients are acutely ill and there’s an ability to get these patients better—and see a change in their medical condition in a day or two. There’s more immediate gratification in terms of the effort that we put in caring for a patient.

Q: What do you like least?

A: The paperwork. At my hospital, a lot of it is computerized. But there are tons of checklists, tons of quality measures that need to be addressed, which is good. Still, it ends up bogging down our ability to take care of the patient. For example, a patient comes in for pneumonia and you have to make sure that some of their chronic issues (e.g. diabetes) are addressed. Have they had their hemoglobin A1C checked in the last 60 days? Does it really matter right now when we’re taking care of the patient’s pneumonia that we have to address this? Smoking cessation, yes, it’s very important, and we need to address this, but is it really necessary that we do this at this point when a patient is really ill? I think there’s a lot of these government regulations that they want us to take care of sometimes in the acute setting, which sometimes feels awkward or not necessarily time-appropriate.

Q: You say your training as an internist prepared you for a seamless transition to a hospitalist job, but you also think IM training is “doing a disservice to medicine.” How so?

A: Don’t get me wrong, I love hospital medicine. But I think what we really need is more primary-care doctors. This is not just my commentary on hospital medicine, but all subspecialties. I know specifically speaking that we need more outpatient internists, outpatient family physicians. If there are many internists, they’re not going to have as much need for cardiology or GI, or a lot of other subspecialties. There’s enough of a population of internists that would satisfy the need for internists and obviously the need for subspecialties.

Q: What’s the biggest change in HM you’ve witnessed since you started 10 years ago?

A: Our acceptance as a field by the medical community. Other physicians have now come to be very accepting of our role as the primary caretakers of their hospitalized patients.

Q: Do you consider yourself to have an entrepreneurial spirit or are you more of a solutions-oriented physician?

A: I have more of the entrepreneurial spirit. I’ve been talking to a lot of hospitalists, and what I encourage them to do is completely counter to the current healthcare environment. I’ve been encouraging them to say, “Let’s get a bunch of us together and set up our own hospitalist practice and do it in a way that we can have a certain level of autonomy, but also do it in a way that we can collaborate with the hospital, work intimately with them, and get certain guarantees from them. And do it privately, so that we can maintain our autonomy.” I think that’s important because I see the difference between the private practices and the practices that are owned by a health system. People just care so much more when it’s their own practice.

Q: What are the biggest challenges you face as medical director?

A: Getting everyone to work as a team. Everyone has a different schedule, differing values, and priorities. It’s very important that we work as a team because when one person does something, it impacts what somebody else does.

Q: What’s the most important thing to know when starting an HM group or fixing a broken group?

A: For fixing a group, you have to look at the values of the group of doctors. What are the values? What are the objectives? What are the professional goals? What I’ve encountered in HM is a lot of people are just coming in to get a paycheck. They come in, they do their job, and they like to take care of patients. Don’t get me wrong about that, but they like the freedom and the high competition that’s provided by hospital medicine. Oftentimes they come in, they do their jobs very well, they take care of their patients, and then they’re out the door. They don’t really have an interest in building up that practice or building up something for the hospital. We as doctors are all part of a medical community, we’re part of a medical staff, and it’s very important for us to get involved.

Q: Last year, you became president of SHM’s Philadelphia Tri-State Region chapter. What are your goals?

A: I’ve always been involved with the chapter, but I saw it as a good opportunity to network and talk with more hospitalists. I wanted to get their viewpoints on things and bounce ideas. I’m a very vocal person, so when I hear a good idea, I like to spread it amongst other people. And if I see something that someone said was bad and I hear it from enough people, I like to bring it up and discuss with everybody.

Q: What’s the best part of being an SHM member?

A: Getting to interact with a lot of my colleagues. To see what struggles they’re going through, to see that their struggles are very similar to the struggles that my group is going through, that we’re all in the same boat, and that we need to collaborate a little more to make things work. Instead of each practice trying to reinvent the wheel, we can try to work together and build off each other.

Richard Quinn is a freelance writer in New Jersey.