Practice Management

By now almost everyone has heard about the social network site MySpace. More than 50 million people—mostly between ages 14 and 24—post and view online profiles connected by links to friends in the system. It’s one of the most heavily trafficked sites on the Internet.

MySpace is remarkable not only for consistent, double-digit growth rate, but also because visitors average two hours on the site modifying their profiles, and checking out friends’ profiles and commenting on them. MySpace has become ubiquitous to a generation using this public space to create and modify their identity on a daily basis—with technology that only recently has become available.

While recognizing that it may be a long time before www.hospitalmedicine.org becomes a household destination, the SHM Research Committee aims to generate similar excitement among our peers for connecting with each other over hospital medicine research on the Web.

Chapter Summary

Las Vegas

The SHM Las Vegas Chapter held its quarterly administrative meeting June 26 at Roy’s in Las Vegas. Gary Skankey, MD, infectious disease specialist and associate clinical professor at the University of Nevada School of Medicine, presented “Treating Complicated Skin and Skin Infections in an Era of Increasing Resistance.” The chapter will host a CME Program on surviving sepsis Sept. 28-29. Visit the chapter page for further program details.

Nashville

The SHM Nashville Chapter meeting June 6 at Stoney River restaurant was sponsored by Ortho McNeil and HCA Physician Recruitment. Eric Siegal, MD, with the University of Wisconsin Hospital in Madison, was the featured presenter and led an interactive session during “Malpractice for the Hospitalists: Identifying and Mitigating Risks.” The next meeting is scheduled for this month. Details will be posted at a later date.

At the SHM Research Committee meeting in Dallas in May, the conversation covered many topics, including the need for research mentorship, training, and career development. Plans for short- and medium-term measures to support SHM members in these areas are in the works, with a focus on Internet-based resources.

Over the long term, the committee would like to see its efforts result in national, high-impact hospital medicine studies and well-trained researchers. Whether driven by a curiosity in a particular area and/or the desire to provide better care by incorporating the best research, the universal challenge is to free enough time to pursue the answers and for appropriate recognition systems to be in place—be they promotion, funding to support further work, or recognition that leads to new connections.

The 249 abstracts published in a supplement to the Journal of Hospital Medicine only hinted at the depth and enthusiasm behind SHM members’ work. Anyone who walked through the exhibit hall during the poster session at the SHM Annual Meeting and talked with the people behind the research was impressed with their dedication and relative youth. They are the future of hospital medicine and are looking for ways to collaborate and continue to learn. The SHM Research Committee is dedicated to finding ways to support their efforts.

It seems as if many SHM members either engage in research, think about a research project, or wish they could evaluate their everyday practice in a way that can help others. However, it is difficult to discern how best to support individual hospitalists working in diverse settings across the country.

Because clinical responsibilities will not slow down anytime soon, we will have to work within the current, hectic environment and use technology as an equalizer to enable communication. In the spectrum of professional medical societies, SHM could be considered similar to the age 14-24 demographic attracted to the fluidity, instant communication/information and innovation that fuels MySpace.

Our long-term research goals could be powerfully advanced by a peer-catalyzed hospitalist research network.

The term “research network” can refer to many types of collaboration. One type that has been successful is the collection, analysis, and reporting of data in a registry or repository. In this example, medical care can be measured through the collection, analysis, and reporting of data. The National Cardiovascular Data Registry (established in 1998 by the American College of Cardiology Foundation) is a well-known example, but there are many others that have been organized for the purposes of improving quality and providing educational and research activities.

A second type of research network is the developing partnership between the American Medical Association (AMA) and Sermo, an online community where physicians exchange medical opinions. The partnership attempts to use technology to harness innovation, support physicians, and improve the capability of a peer network to influence the care patients receive by letting them share information with each other regarding patient care, pertinent scientific research, and advocacy issues. This is a looser network—without the constraints of data dictionaries—that relies on technology to make the connection between physician peers. While its start-up costs may be lower, its impact will be more difficult to measure.

A third example is the Gotham Prize for Cancer Research, which requires investigators to qualify by logging onto a Web site (www.gothamprize.org), posting a short proposal, and answering questions. If accepted by the expert panel of cancer researchers into this active forum, the new member will not only be eligible to receive the annual prize for the best idea, these individuals and their ideas will be matched to funding agencies and other scientists who may be able to support, assist, and/or collaborate. This limited-access network requires more facilitation than the previous AMA example, and the incentives and outcomes are more clearly defined.

The SHM Research Committee sees potential in exploring a network for hospital medicine researchers, through which members can access resources, collaborate, and innovate. Internet technology has the potential to level the playing field and erase the barriers of time differences and geography. By organizing around areas of interest designed to attract a critical mass of interested hospitalists, the goal of this network is to position SHM to lead hospital medicine research and ensure long-term success and sustainability by enabling powerful, high-impact studies in hospital medicine and supporting well-trained hospitalist researchers. Although this discussion is in the early stages of development, the SHM Research Committee plans to consider the following questions:

click for large version

How would a network help hospital medicine and hospitalists? During the meeting in May in Dallas, the SHM Research Committee articulated the need for research mentorship, training, and career development. Any proposed network must further these aims. Hospital medicine investigators and SHM members would be involved in refining these goals at the earliest stages. Opportunities for training a new generation of hospital medicine investigators and strengthening the existing ones through such a network will be explored, including options for training in outcomes research and opportunities to link participants with mentors.

 What questions should a network focus on? Hospitalists are well positioned to lead or collaborate on a range of key questions—questions that, in the short term, likely will focus on effectiveness and implementation research (related to quality improvement). Over the longer term, hospitalists should position themselves to be involved in all facets of clinical translational research, including T1 (bench-to-bedside research) and T2 (effectiveness research, such as larger randomized studies, and health services research). As hospital medicine grows, the potential areas where hospitalists might focus their scientific interests will expand. As hospitalists assume greater roles in caring for patients outside general medicine (e.g., surgical, cardiovascular, neurology, and oncology patients), the breadth of scientific inquiry will expand. In many of these cases, research networks exist; SHM will have to facilitate collaboration whenever possible.

How will the network engage a broad swath of hospitalists? By selecting research questions important to public health and anticipating a changing clinical environment, we hope to enhance the interest and relevance of an SHM research network. The SHM Research Committee will focus on how best to design a research network that is practical and useful for hospital medicine researchers and enable straightforward studies. A main goal will be promoting visibility for investigators and coordinators through opportunities for authorship and presentation of results at national meetings.

Healthcare reform has become a hot political issue again—more than a year before the presidential election. All three leading Democratic candidates (Hillary Clinton, Barack Obama, and John Edwards) have proposed some sort of a central institute to assess treatment options and disseminate research and information to providers. Hospitalists (as generalists and team leaders in an arena where approximately 30% of the healthcare dollar is spent) are a key part of any national solution.

Whether this research requires a catalyst such as a hospitalist network—and what that network would look like—remains to be seen. The SHM Research Committee is considering mechanisms to provide research mentorship, training, and career development, and weighing the best use of resources. We count on your input. Contact Carolyn Brennan, director of research program development for SHM, at cbrennan@hospitalmedicine.org for more information or to get involved. TH

SHM Behind the Scenes

PRIS updates in Salt Lake City

By Todd Von Deak

Each year, one of the premier events in pediatric hospital medicine is a summer conference presented by the American Academy of Pediatrics (AAP), the Ambulatory Pediatric Association (APA), and SHM. This year’s conference, held last month in Salt Lake City under the lead sponsorship of the AAP, was no exception.

More than 300 pediatric hospitalists, medical directors, residents, nurse practitioners, and physician assistants came together for four days to network, get answers, and learn from colleagues at 30 sessions. Charlie Homer, CEO of the National Institute for Children’s HealthCare Quality in Cambridge, Mass., was the keynote speaker. Dr. Homer highlighted the roles hospitalists can and must play to improve children’s health, and challenged all present to create a dashboard that includes quality indicators for care that is efficient, equitable, evidence-based, safe, and family-centered.

Leaders from the AAP, APA, and SHM opened the morning sessions the next day with brief presentations that highlighted the role of pediatric hospitalists in each organization, and the potential to work together to continue to develop pediatric hospital medicine and advance the care of hospitalized children. Participants were then free to choose from more than 16 sessions ranging from clinical issues such as the management of apparent life-threatening events and appropriate maintenance IV fluids, to practice management (Coding 101 and 201), quality improvement, and resident teaching and research.

Capping the schedule of events was a luncheon presentation from Christopher P. Landrigan, MD, director of the Pediatric Research in Inpatient Settings network. He presented “PRIS Update: The Need for Collaborative Hospitalist Research in 2007.” PRIS is an independent collaborative entity established by the same organizations that sponsor the Salt Lake City conference and is designed to allow for collaborative study of key questions in inpatient pediatrics.

Linda Snelling, MD, inpatient director and chief of pediatric critical care at Hasbro Children’s Hospital in Providence, R.I., followed with a talk on how pediatric hospitalists can effectively negotiate for themselves and the field. Her key insights included, “ ‘No.’ is a complete sentence.”

According to Jack Percelay, MD, past chair of SHM’s Pediatric Committee and a practicing pediatric hospitalist in New York and New Jersey, the conference exceeded its goals. “The energy at the conference was tremendous,” he said. “Sessions were filled with attendees learning of and debating cutting-edge issues for pediatric hospitalists. The buzz in the hotel was so intoxicating we were worried that we were violating Salt Lake City liquor laws. The AAP put on a spectacular meeting. SHM is looking forward to following this tradition of excellence as we take the lead for putting on an even larger meeting in Denver July 24-27, 2008.”

Given that the 2008 meeting sold out six weeks in advance, pediatric hospitalists will do well to stay tuned to The Hospitalist and visit SHM’s Web site, www.hospitalmedicine.org, for more details as the 2008 conference approaches. TH

By now almost everyone has heard about the social network site MySpace. More than 50 million people—mostly between ages 14 and 24—post and view online profiles connected by links to friends in the system. It’s one of the most heavily trafficked sites on the Internet.

MySpace is remarkable not only for consistent, double-digit growth rate, but also because visitors average two hours on the site modifying their profiles, and checking out friends’ profiles and commenting on them. MySpace has become ubiquitous to a generation using this public space to create and modify their identity on a daily basis—with technology that only recently has become available.

While recognizing that it may be a long time before www.hospitalmedicine.org becomes a household destination, the SHM Research Committee aims to generate similar excitement among our peers for connecting with each other over hospital medicine research on the Web.

Chapter Summary

Las Vegas

The SHM Las Vegas Chapter held its quarterly administrative meeting June 26 at Roy’s in Las Vegas. Gary Skankey, MD, infectious disease specialist and associate clinical professor at the University of Nevada School of Medicine, presented “Treating Complicated Skin and Skin Infections in an Era of Increasing Resistance.” The chapter will host a CME Program on surviving sepsis Sept. 28-29. Visit the chapter page for further program details.

Nashville

The SHM Nashville Chapter meeting June 6 at Stoney River restaurant was sponsored by Ortho McNeil and HCA Physician Recruitment. Eric Siegal, MD, with the University of Wisconsin Hospital in Madison, was the featured presenter and led an interactive session during “Malpractice for the Hospitalists: Identifying and Mitigating Risks.” The next meeting is scheduled for this month. Details will be posted at a later date.

At the SHM Research Committee meeting in Dallas in May, the conversation covered many topics, including the need for research mentorship, training, and career development. Plans for short- and medium-term measures to support SHM members in these areas are in the works, with a focus on Internet-based resources.

Over the long term, the committee would like to see its efforts result in national, high-impact hospital medicine studies and well-trained researchers. Whether driven by a curiosity in a particular area and/or the desire to provide better care by incorporating the best research, the universal challenge is to free enough time to pursue the answers and for appropriate recognition systems to be in place—be they promotion, funding to support further work, or recognition that leads to new connections.

The 249 abstracts published in a supplement to the Journal of Hospital Medicine only hinted at the depth and enthusiasm behind SHM members’ work. Anyone who walked through the exhibit hall during the poster session at the SHM Annual Meeting and talked with the people behind the research was impressed with their dedication and relative youth. They are the future of hospital medicine and are looking for ways to collaborate and continue to learn. The SHM Research Committee is dedicated to finding ways to support their efforts.

It seems as if many SHM members either engage in research, think about a research project, or wish they could evaluate their everyday practice in a way that can help others. However, it is difficult to discern how best to support individual hospitalists working in diverse settings across the country.

Because clinical responsibilities will not slow down anytime soon, we will have to work within the current, hectic environment and use technology as an equalizer to enable communication. In the spectrum of professional medical societies, SHM could be considered similar to the age 14-24 demographic attracted to the fluidity, instant communication/information and innovation that fuels MySpace.

Our long-term research goals could be powerfully advanced by a peer-catalyzed hospitalist research network.

The term “research network” can refer to many types of collaboration. One type that has been successful is the collection, analysis, and reporting of data in a registry or repository. In this example, medical care can be measured through the collection, analysis, and reporting of data. The National Cardiovascular Data Registry (established in 1998 by the American College of Cardiology Foundation) is a well-known example, but there are many others that have been organized for the purposes of improving quality and providing educational and research activities.

A second type of research network is the developing partnership between the American Medical Association (AMA) and Sermo, an online community where physicians exchange medical opinions. The partnership attempts to use technology to harness innovation, support physicians, and improve the capability of a peer network to influence the care patients receive by letting them share information with each other regarding patient care, pertinent scientific research, and advocacy issues. This is a looser network—without the constraints of data dictionaries—that relies on technology to make the connection between physician peers. While its start-up costs may be lower, its impact will be more difficult to measure.

A third example is the Gotham Prize for Cancer Research, which requires investigators to qualify by logging onto a Web site (www.gothamprize.org), posting a short proposal, and answering questions. If accepted by the expert panel of cancer researchers into this active forum, the new member will not only be eligible to receive the annual prize for the best idea, these individuals and their ideas will be matched to funding agencies and other scientists who may be able to support, assist, and/or collaborate. This limited-access network requires more facilitation than the previous AMA example, and the incentives and outcomes are more clearly defined.

The SHM Research Committee sees potential in exploring a network for hospital medicine researchers, through which members can access resources, collaborate, and innovate. Internet technology has the potential to level the playing field and erase the barriers of time differences and geography. By organizing around areas of interest designed to attract a critical mass of interested hospitalists, the goal of this network is to position SHM to lead hospital medicine research and ensure long-term success and sustainability by enabling powerful, high-impact studies in hospital medicine and supporting well-trained hospitalist researchers. Although this discussion is in the early stages of development, the SHM Research Committee plans to consider the following questions:

click for large version

How would a network help hospital medicine and hospitalists? During the meeting in May in Dallas, the SHM Research Committee articulated the need for research mentorship, training, and career development. Any proposed network must further these aims. Hospital medicine investigators and SHM members would be involved in refining these goals at the earliest stages. Opportunities for training a new generation of hospital medicine investigators and strengthening the existing ones through such a network will be explored, including options for training in outcomes research and opportunities to link participants with mentors.

 What questions should a network focus on? Hospitalists are well positioned to lead or collaborate on a range of key questions—questions that, in the short term, likely will focus on effectiveness and implementation research (related to quality improvement). Over the longer term, hospitalists should position themselves to be involved in all facets of clinical translational research, including T1 (bench-to-bedside research) and T2 (effectiveness research, such as larger randomized studies, and health services research). As hospital medicine grows, the potential areas where hospitalists might focus their scientific interests will expand. As hospitalists assume greater roles in caring for patients outside general medicine (e.g., surgical, cardiovascular, neurology, and oncology patients), the breadth of scientific inquiry will expand. In many of these cases, research networks exist; SHM will have to facilitate collaboration whenever possible.

How will the network engage a broad swath of hospitalists? By selecting research questions important to public health and anticipating a changing clinical environment, we hope to enhance the interest and relevance of an SHM research network. The SHM Research Committee will focus on how best to design a research network that is practical and useful for hospital medicine researchers and enable straightforward studies. A main goal will be promoting visibility for investigators and coordinators through opportunities for authorship and presentation of results at national meetings.

Healthcare reform has become a hot political issue again—more than a year before the presidential election. All three leading Democratic candidates (Hillary Clinton, Barack Obama, and John Edwards) have proposed some sort of a central institute to assess treatment options and disseminate research and information to providers. Hospitalists (as generalists and team leaders in an arena where approximately 30% of the healthcare dollar is spent) are a key part of any national solution.

Whether this research requires a catalyst such as a hospitalist network—and what that network would look like—remains to be seen. The SHM Research Committee is considering mechanisms to provide research mentorship, training, and career development, and weighing the best use of resources. We count on your input. Contact Carolyn Brennan, director of research program development for SHM, at cbrennan@hospitalmedicine.org for more information or to get involved. TH

SHM Behind the Scenes

PRIS updates in Salt Lake City

By Todd Von Deak

Each year, one of the premier events in pediatric hospital medicine is a summer conference presented by the American Academy of Pediatrics (AAP), the Ambulatory Pediatric Association (APA), and SHM. This year’s conference, held last month in Salt Lake City under the lead sponsorship of the AAP, was no exception.

More than 300 pediatric hospitalists, medical directors, residents, nurse practitioners, and physician assistants came together for four days to network, get answers, and learn from colleagues at 30 sessions. Charlie Homer, CEO of the National Institute for Children’s HealthCare Quality in Cambridge, Mass., was the keynote speaker. Dr. Homer highlighted the roles hospitalists can and must play to improve children’s health, and challenged all present to create a dashboard that includes quality indicators for care that is efficient, equitable, evidence-based, safe, and family-centered.

Leaders from the AAP, APA, and SHM opened the morning sessions the next day with brief presentations that highlighted the role of pediatric hospitalists in each organization, and the potential to work together to continue to develop pediatric hospital medicine and advance the care of hospitalized children. Participants were then free to choose from more than 16 sessions ranging from clinical issues such as the management of apparent life-threatening events and appropriate maintenance IV fluids, to practice management (Coding 101 and 201), quality improvement, and resident teaching and research.

Capping the schedule of events was a luncheon presentation from Christopher P. Landrigan, MD, director of the Pediatric Research in Inpatient Settings network. He presented “PRIS Update: The Need for Collaborative Hospitalist Research in 2007.” PRIS is an independent collaborative entity established by the same organizations that sponsor the Salt Lake City conference and is designed to allow for collaborative study of key questions in inpatient pediatrics.

Linda Snelling, MD, inpatient director and chief of pediatric critical care at Hasbro Children’s Hospital in Providence, R.I., followed with a talk on how pediatric hospitalists can effectively negotiate for themselves and the field. Her key insights included, “ ‘No.’ is a complete sentence.”

According to Jack Percelay, MD, past chair of SHM’s Pediatric Committee and a practicing pediatric hospitalist in New York and New Jersey, the conference exceeded its goals. “The energy at the conference was tremendous,” he said. “Sessions were filled with attendees learning of and debating cutting-edge issues for pediatric hospitalists. The buzz in the hotel was so intoxicating we were worried that we were violating Salt Lake City liquor laws. The AAP put on a spectacular meeting. SHM is looking forward to following this tradition of excellence as we take the lead for putting on an even larger meeting in Denver July 24-27, 2008.”

Given that the 2008 meeting sold out six weeks in advance, pediatric hospitalists will do well to stay tuned to The Hospitalist and visit SHM’s Web site, www.hospitalmedicine.org, for more details as the 2008 conference approaches. TH

By now almost everyone has heard about the social network site MySpace. More than 50 million people—mostly between ages 14 and 24—post and view online profiles connected by links to friends in the system. It’s one of the most heavily trafficked sites on the Internet.

MySpace is remarkable not only for consistent, double-digit growth rate, but also because visitors average two hours on the site modifying their profiles, and checking out friends’ profiles and commenting on them. MySpace has become ubiquitous to a generation using this public space to create and modify their identity on a daily basis—with technology that only recently has become available.

While recognizing that it may be a long time before www.hospitalmedicine.org becomes a household destination, the SHM Research Committee aims to generate similar excitement among our peers for connecting with each other over hospital medicine research on the Web.

Chapter Summary

Las Vegas

The SHM Las Vegas Chapter held its quarterly administrative meeting June 26 at Roy’s in Las Vegas. Gary Skankey, MD, infectious disease specialist and associate clinical professor at the University of Nevada School of Medicine, presented “Treating Complicated Skin and Skin Infections in an Era of Increasing Resistance.” The chapter will host a CME Program on surviving sepsis Sept. 28-29. Visit the chapter page for further program details.

Nashville

The SHM Nashville Chapter meeting June 6 at Stoney River restaurant was sponsored by Ortho McNeil and HCA Physician Recruitment. Eric Siegal, MD, with the University of Wisconsin Hospital in Madison, was the featured presenter and led an interactive session during “Malpractice for the Hospitalists: Identifying and Mitigating Risks.” The next meeting is scheduled for this month. Details will be posted at a later date.

At the SHM Research Committee meeting in Dallas in May, the conversation covered many topics, including the need for research mentorship, training, and career development. Plans for short- and medium-term measures to support SHM members in these areas are in the works, with a focus on Internet-based resources.

Over the long term, the committee would like to see its efforts result in national, high-impact hospital medicine studies and well-trained researchers. Whether driven by a curiosity in a particular area and/or the desire to provide better care by incorporating the best research, the universal challenge is to free enough time to pursue the answers and for appropriate recognition systems to be in place—be they promotion, funding to support further work, or recognition that leads to new connections.

The 249 abstracts published in a supplement to the Journal of Hospital Medicine only hinted at the depth and enthusiasm behind SHM members’ work. Anyone who walked through the exhibit hall during the poster session at the SHM Annual Meeting and talked with the people behind the research was impressed with their dedication and relative youth. They are the future of hospital medicine and are looking for ways to collaborate and continue to learn. The SHM Research Committee is dedicated to finding ways to support their efforts.

It seems as if many SHM members either engage in research, think about a research project, or wish they could evaluate their everyday practice in a way that can help others. However, it is difficult to discern how best to support individual hospitalists working in diverse settings across the country.

Because clinical responsibilities will not slow down anytime soon, we will have to work within the current, hectic environment and use technology as an equalizer to enable communication. In the spectrum of professional medical societies, SHM could be considered similar to the age 14-24 demographic attracted to the fluidity, instant communication/information and innovation that fuels MySpace.

Our long-term research goals could be powerfully advanced by a peer-catalyzed hospitalist research network.

The term “research network” can refer to many types of collaboration. One type that has been successful is the collection, analysis, and reporting of data in a registry or repository. In this example, medical care can be measured through the collection, analysis, and reporting of data. The National Cardiovascular Data Registry (established in 1998 by the American College of Cardiology Foundation) is a well-known example, but there are many others that have been organized for the purposes of improving quality and providing educational and research activities.

A second type of research network is the developing partnership between the American Medical Association (AMA) and Sermo, an online community where physicians exchange medical opinions. The partnership attempts to use technology to harness innovation, support physicians, and improve the capability of a peer network to influence the care patients receive by letting them share information with each other regarding patient care, pertinent scientific research, and advocacy issues. This is a looser network—without the constraints of data dictionaries—that relies on technology to make the connection between physician peers. While its start-up costs may be lower, its impact will be more difficult to measure.

A third example is the Gotham Prize for Cancer Research, which requires investigators to qualify by logging onto a Web site (www.gothamprize.org), posting a short proposal, and answering questions. If accepted by the expert panel of cancer researchers into this active forum, the new member will not only be eligible to receive the annual prize for the best idea, these individuals and their ideas will be matched to funding agencies and other scientists who may be able to support, assist, and/or collaborate. This limited-access network requires more facilitation than the previous AMA example, and the incentives and outcomes are more clearly defined.

The SHM Research Committee sees potential in exploring a network for hospital medicine researchers, through which members can access resources, collaborate, and innovate. Internet technology has the potential to level the playing field and erase the barriers of time differences and geography. By organizing around areas of interest designed to attract a critical mass of interested hospitalists, the goal of this network is to position SHM to lead hospital medicine research and ensure long-term success and sustainability by enabling powerful, high-impact studies in hospital medicine and supporting well-trained hospitalist researchers. Although this discussion is in the early stages of development, the SHM Research Committee plans to consider the following questions:

click for large version

How would a network help hospital medicine and hospitalists? During the meeting in May in Dallas, the SHM Research Committee articulated the need for research mentorship, training, and career development. Any proposed network must further these aims. Hospital medicine investigators and SHM members would be involved in refining these goals at the earliest stages. Opportunities for training a new generation of hospital medicine investigators and strengthening the existing ones through such a network will be explored, including options for training in outcomes research and opportunities to link participants with mentors.

 What questions should a network focus on? Hospitalists are well positioned to lead or collaborate on a range of key questions—questions that, in the short term, likely will focus on effectiveness and implementation research (related to quality improvement). Over the longer term, hospitalists should position themselves to be involved in all facets of clinical translational research, including T1 (bench-to-bedside research) and T2 (effectiveness research, such as larger randomized studies, and health services research). As hospital medicine grows, the potential areas where hospitalists might focus their scientific interests will expand. As hospitalists assume greater roles in caring for patients outside general medicine (e.g., surgical, cardiovascular, neurology, and oncology patients), the breadth of scientific inquiry will expand. In many of these cases, research networks exist; SHM will have to facilitate collaboration whenever possible.

How will the network engage a broad swath of hospitalists? By selecting research questions important to public health and anticipating a changing clinical environment, we hope to enhance the interest and relevance of an SHM research network. The SHM Research Committee will focus on how best to design a research network that is practical and useful for hospital medicine researchers and enable straightforward studies. A main goal will be promoting visibility for investigators and coordinators through opportunities for authorship and presentation of results at national meetings.

Healthcare reform has become a hot political issue again—more than a year before the presidential election. All three leading Democratic candidates (Hillary Clinton, Barack Obama, and John Edwards) have proposed some sort of a central institute to assess treatment options and disseminate research and information to providers. Hospitalists (as generalists and team leaders in an arena where approximately 30% of the healthcare dollar is spent) are a key part of any national solution.

Whether this research requires a catalyst such as a hospitalist network—and what that network would look like—remains to be seen. The SHM Research Committee is considering mechanisms to provide research mentorship, training, and career development, and weighing the best use of resources. We count on your input. Contact Carolyn Brennan, director of research program development for SHM, at cbrennan@hospitalmedicine.org for more information or to get involved. TH

SHM Behind the Scenes

PRIS updates in Salt Lake City

By Todd Von Deak

Each year, one of the premier events in pediatric hospital medicine is a summer conference presented by the American Academy of Pediatrics (AAP), the Ambulatory Pediatric Association (APA), and SHM. This year’s conference, held last month in Salt Lake City under the lead sponsorship of the AAP, was no exception.

More than 300 pediatric hospitalists, medical directors, residents, nurse practitioners, and physician assistants came together for four days to network, get answers, and learn from colleagues at 30 sessions. Charlie Homer, CEO of the National Institute for Children’s HealthCare Quality in Cambridge, Mass., was the keynote speaker. Dr. Homer highlighted the roles hospitalists can and must play to improve children’s health, and challenged all present to create a dashboard that includes quality indicators for care that is efficient, equitable, evidence-based, safe, and family-centered.

Leaders from the AAP, APA, and SHM opened the morning sessions the next day with brief presentations that highlighted the role of pediatric hospitalists in each organization, and the potential to work together to continue to develop pediatric hospital medicine and advance the care of hospitalized children. Participants were then free to choose from more than 16 sessions ranging from clinical issues such as the management of apparent life-threatening events and appropriate maintenance IV fluids, to practice management (Coding 101 and 201), quality improvement, and resident teaching and research.

Capping the schedule of events was a luncheon presentation from Christopher P. Landrigan, MD, director of the Pediatric Research in Inpatient Settings network. He presented “PRIS Update: The Need for Collaborative Hospitalist Research in 2007.” PRIS is an independent collaborative entity established by the same organizations that sponsor the Salt Lake City conference and is designed to allow for collaborative study of key questions in inpatient pediatrics.

Linda Snelling, MD, inpatient director and chief of pediatric critical care at Hasbro Children’s Hospital in Providence, R.I., followed with a talk on how pediatric hospitalists can effectively negotiate for themselves and the field. Her key insights included, “ ‘No.’ is a complete sentence.”

According to Jack Percelay, MD, past chair of SHM’s Pediatric Committee and a practicing pediatric hospitalist in New York and New Jersey, the conference exceeded its goals. “The energy at the conference was tremendous,” he said. “Sessions were filled with attendees learning of and debating cutting-edge issues for pediatric hospitalists. The buzz in the hotel was so intoxicating we were worried that we were violating Salt Lake City liquor laws. The AAP put on a spectacular meeting. SHM is looking forward to following this tradition of excellence as we take the lead for putting on an even larger meeting in Denver July 24-27, 2008.”

Given that the 2008 meeting sold out six weeks in advance, pediatric hospitalists will do well to stay tuned to The Hospitalist and visit SHM’s Web site, www.hospitalmedicine.org, for more details as the 2008 conference approaches. TH

Isn’t it ironic that just as America is waking up to the importance of primary care medicine, our own representative organizations are selling us down the river?

The training of primary care physicians has for decades allowed us to branch out and follow our patients in multiple sites of care. We are the masters of managing care across this continuum.

Government and big business are finally recognizing that they need to bolster primary care to manage patients in the new chronic care medical home models. They are finally recognizing the need to better supply, equip, and finance primary care physicians.

The American College of Physicians (ACP), the American Academy of Family Practice (AAFP), and the American Medical Association all appear to support this concept. So where is the irony?

The American Board of Internal Medicine (ABIM), along with the aforementioned groups and others, continues to carve medicine into ever increasing sub areas, based on sites of care and interests. Hospitalists (who already have three branches—general hospitalists, proceduralists, and nocturnists) are seeking special certification recognition through ABIM. Palliative care is a new certification. These branches of medicine deserve recognition, but do we need all these fractured certifications?

Soon, no primary care physicians will be certified as capable of practicing in multiple sites of care without multiple certifications for each separate site and individual function. Soon there will be no “general” primary care physicians. Can hospitalists equally manage the whole continuum of care, or will they need to become generalists again to do the job?

Medicine teaches us to care for the whole person—body, mind, and spirit—not just individual parts. I urge the ABIM, the ACP, the AAFP, the AMA, SHM, and others to stop this fracturing of primary care. Now is the time to promote the generalists. Now is the time to lift all primary care-related areas of medicine together, leaving no one behind.

John M. Colombo, MD

HAN/Colombo

Crozer Keystone Health Network

Isn’t it ironic that just as America is waking up to the importance of primary care medicine, our own representative organizations are selling us down the river?

The training of primary care physicians has for decades allowed us to branch out and follow our patients in multiple sites of care. We are the masters of managing care across this continuum.

Government and big business are finally recognizing that they need to bolster primary care to manage patients in the new chronic care medical home models. They are finally recognizing the need to better supply, equip, and finance primary care physicians.

The American College of Physicians (ACP), the American Academy of Family Practice (AAFP), and the American Medical Association all appear to support this concept. So where is the irony?

The American Board of Internal Medicine (ABIM), along with the aforementioned groups and others, continues to carve medicine into ever increasing sub areas, based on sites of care and interests. Hospitalists (who already have three branches—general hospitalists, proceduralists, and nocturnists) are seeking special certification recognition through ABIM. Palliative care is a new certification. These branches of medicine deserve recognition, but do we need all these fractured certifications?

Soon, no primary care physicians will be certified as capable of practicing in multiple sites of care without multiple certifications for each separate site and individual function. Soon there will be no “general” primary care physicians. Can hospitalists equally manage the whole continuum of care, or will they need to become generalists again to do the job?

Medicine teaches us to care for the whole person—body, mind, and spirit—not just individual parts. I urge the ABIM, the ACP, the AAFP, the AMA, SHM, and others to stop this fracturing of primary care. Now is the time to promote the generalists. Now is the time to lift all primary care-related areas of medicine together, leaving no one behind.

John M. Colombo, MD

HAN/Colombo

Crozer Keystone Health Network

Isn’t it ironic that just as America is waking up to the importance of primary care medicine, our own representative organizations are selling us down the river?

The training of primary care physicians has for decades allowed us to branch out and follow our patients in multiple sites of care. We are the masters of managing care across this continuum.

Government and big business are finally recognizing that they need to bolster primary care to manage patients in the new chronic care medical home models. They are finally recognizing the need to better supply, equip, and finance primary care physicians.

The American College of Physicians (ACP), the American Academy of Family Practice (AAFP), and the American Medical Association all appear to support this concept. So where is the irony?

The American Board of Internal Medicine (ABIM), along with the aforementioned groups and others, continues to carve medicine into ever increasing sub areas, based on sites of care and interests. Hospitalists (who already have three branches—general hospitalists, proceduralists, and nocturnists) are seeking special certification recognition through ABIM. Palliative care is a new certification. These branches of medicine deserve recognition, but do we need all these fractured certifications?

Soon, no primary care physicians will be certified as capable of practicing in multiple sites of care without multiple certifications for each separate site and individual function. Soon there will be no “general” primary care physicians. Can hospitalists equally manage the whole continuum of care, or will they need to become generalists again to do the job?

Medicine teaches us to care for the whole person—body, mind, and spirit—not just individual parts. I urge the ABIM, the ACP, the AAFP, the AMA, SHM, and others to stop this fracturing of primary care. Now is the time to promote the generalists. Now is the time to lift all primary care-related areas of medicine together, leaving no one behind.

John M. Colombo, MD

HAN/Colombo

Crozer Keystone Health Network

Retrospective Study of Symptoms in Post-Discharge Patients

Epstein K, Juarez E, Loya K, et al. Frequency of new or worsening symptoms in the posthospitalization period. J Hosp Med. March/April 2007;2(2):58-68.

As hospital stays shorten and acuity rises, patients often are discharged with complex instructions and discharge plans including home health services, physical therapy, hospice service, antibiotic infusions, and follow-up appointments. The potential for new or progressive symptoms in the days following discharge is an important parameter in assessing whether our planning is safe and effective.

The researchers in this study investigated the post-discharge period using a retrospective analysis of new or worsening symptoms within two to five days of hospital discharge among 15,767 patients surveyed between May 1 and Oct. 31, 2003. Patients were all under the care of hospitalists employed by IPC, a large private hospitalist group based in North Hollywood, Calif. Total discharges from which this cohort was selected numbered 48,236.

Staff with medical backgrounds conducted a scripted survey by phone. Licensed nursing personnel contacted those patients whose answers to initial questions suggested they were at high risk for postdischarge complications. A five-point Likert scale was used so patients could rate their overall health status in addition to specific symptomatology ranging from abdominal pain to bleeding. Other questions targeted pick-up and administration of prescribed medications, insulin regimen adherence, and implementation of home health services.

Among all patients discharged, 32.7% were contacted within two days of discharge. The mean age was 60.1 years, and 57% were female. Ethnicity and socioeconomic status were not reported. Medicare and HMOs were the most common type of insurance. Of the 15,767 patients contacted, 11.9% reported symptoms that were new or worsening since discharge; of this subgroup, 64% had new symptoms whereas 36% had “worse” symptoms.

Women were more likely than men to report new or worsening symptoms, and patients who rated themselves as having a poor health status were more likely to have new or worsening symptoms. Younger patients were less likely to report new or worsening symptoms, particularly younger men. Those with new or worse symptoms were slightly more likely to have made a follow-up appointment but also more likely to have a problem with their medications. Interestingly, there was no correlation between self-rated health status and reported severity of illness based on the diagnosis related group (DRG) score. Patients discharged with a DRG of chest pain were less likely to report symptoms than all other patients.

The authors acknowledge the low response rate (32.7%) relative to the 48,236 discharges during the study period. Logistic challenges, resource limitations, and erroneous contact information precluded successful contact for the remainder of patients. The magnitude of this exclusion effect essentially precludes statistically valid extrapolation to the inception cohort (all discharges). For example, in a sensitivity analysis where all the excluded patients are assumed to have developed new or worsening symptoms, the actual rate overall would have been 71%. If none developed new or worsening symptoms, that rate would be 3.8%. The rate for the inception cohort may or may not approximate the 11.9% found among the studied patients. There is insufficient evidence to determine whether the studied cohort reflects the entire population of discharged patients.

To their credit, no such analysis or interpretation is claimed or intended by the authors, and the information derived from the included cohort nonetheless provides interesting and important descriptive data.

Ethnicity and cultural factors were not taken into consideration. One might postulate that language barriers could affect compliance and symptom reporting. Day-of-the-week and holiday status also were not reported with regard to discharge. It would be interesting and useful to know whether access to pharmacy and other resources varied in this regard and whether symptom reporting was affected by such timing.

In the final analysis, this study suggests hospitalists remain alert to possible problems that might develop during the vulnerable first few days following discharge. It reminds us to advise patients how to receive prompt and knowledgeable medical advice from someone familiar with their hospital care prior to their first scheduled follow-up.

Based on the reported rate of new or worsening symptoms, should a post-discharge clinic be part of hospitalists’ scope of practice, at least for selected patients? Can subsets of patients who would benefit most from such intervention be identified? These and many more questions are raised by this study. We look forward to further research into the best process for ensuring optimal outcomes in the immediate post-discharge period.

Rosiglitazone’s Effect on MI Risk in Diabetes Patients

Nissen SE, Wolski K. Effect of rosiglitazone on the risk of myocardial infarction and death from cardiovascular causes. N Engl J Med. 2007 June 14;356(24):2457-2471.

Cardiovascular causes account for more than 65% of deaths in diabetic patients. Rosiglitazone—a thiazolidinedione-class drug—has been broadly used in diabetes, but its effect on cardiovascular morbidity and mortality has not been conclusively determined. The authors initiated this meta-analysis to determine the effect of rosiglitazone on the risk of myocardial infarction (MI) and death from cardiovascular causes in diabetics.

The meta-analysis included 42 trials from three data sources. Forty trials were obtained from the Food and Drug Administration (FDA) Web site and the GlaxoSmithKline clinical trials registry. The third data source comprised two recent large, well-known trials: the Diabetes Reduction Assessment with Ramipril and Rosiglitazone Medication (DREAM) and the A Diabetes Outcome Prevention Trial (ADOPT).1-2 The authors’ inclusion criteria were a study with a duration of more than 24 weeks, the use of a randomized control group not receiving rosiglitazone (placebo or comparator drug), and the availability of outcome data for MI and death from cardiovascular causes.

The studies included 15,560 patients randomly assigned to regimens that included rosiglitazone and 12,283 patients to comparator groups that did not include rosiglitazone.

The authors reviewed the data summaries of the 42 trials and tabulated adverse events (not reported as outcomes) of MI and death from cardiovascular causes. Hazard ratios could not be calculated since time-to-event data were lacking. Summary data also precluded the ability to determine whether the same patient suffered both an MI and death from cardiovascular causes.

Results of the authors’ statistical analyses included odds ratios and 95% confidence intervals to assess the risk associated with the rosiglitazone group as well as the subgroups of metformin, sulfonylurea, insulin, and placebo versus rosiglitazone.

The authors tabulated 86 MIs and 39 unadjudicated deaths from cardiovascular causes in the rosiglitazone group, and 72 MIs plus 22 deaths from cardiovascular causes in the control group.

The main conclusion was that rosiglitazone was associated with a statistically significant increase in the risk of MI (odds ratio 1.43, 95% confidence interval 1.03 to 1.98, p=0.03), but was not associated with a statistically significant increase in the risk of death from cardiovascular causes (odds ratio 1.64, 95% confidence interval 0.98 to 2.74, p=0.06).

Additionally, there were no statistical differences between rosiglitazone versus placebo or the individual antidiabetics in the subanalyses.

The authors have recognized the following major limitations in this meta-analysis:

• The low rate of MI is 0.55% (86 of 15,560 cases) in the rosiglitazone group and 0.59% (72 of 12,283 cases) in the control group. The odds ratio of 1.43 was statistically significant in the rosiglitazone group, although the event rate was higher in the control group. The risk of cardiovascular death was not significant, though a trend toward a higher death rate is noted;
• The lack of source data did not allow the use of time event analysis including hazard ratios;
• The definition of MI was unavailable; and
• MI and cardiovascular events were recorded in the trials as adverse events, not outcomes. Therefore, deaths from the latter were unadjudicated.

The authors suggested that the potential mechanism for increased MI in the rosiglitazone group could be its known effects on increasing low-density lipoproteins (LDL), precipitating congestive heart failure and reducing hemoglobin levels.

Rosiglitazone is one of two peroxisome proliferation activated receptor y (PPAR-y) agonists licensed for use in the United States; the other is pioglitazone. The third drug was troglitazone; it was taken off the market in March of 2000 due to hepatotoxicity.

The PPAR-y agonists decrease plasma glycemia by increasing insulin sensitivity in the peripheral tissues. These drugs have complex physiologic effects in activating and suppressing multiple genes, with most target genes being unknown. The observed side effects with rosiglitazone are not necessarily a class effect. Pioglitazone showed a trend toward reducing triglycerides and cardiovascular events, including MI and CVA, in a prospective, randomized trial called Prospective Pioglitazone Clinical Trial in Macrovascular Events (PROACTIVE).

This meta-analysis precipitated an interim analysis of the ongoing Rosiglitazone Evaluated for Cardiovascular Outcomes and Regulation of Glycemia in Diabetes (RECORD) trial.3 The RECORD trial is a randomized, open-label, multicenter, non-inferiority trial of 4,427 patients; 2,220 received add-on rosiglitazone, and 2,227 received a combination of metformin plus sulfonylurea (control group). The primary end point was hospitalization or death from cardiovascular causes. Interim findings were inconclusive for the rosiglitazone group. There was also no evidence of any increase in death from cardiovascular causes or all causes. However, rosiglitazone was found to be associated with an increased risk of congestive heart failure. The data were insufficient to determine whether the drug was associated with increased MI risk.

This important meta-analysis raises concerns about the association of rosiglitazone with cardiovascular events—but do not consider it definitive. For now, patients with comparable alternatives to rosiglitazone (indeed all patients on this medication) should be advised of the undetermined safety concerns. For those who consider rosiglitazone a compelling choice, abrupt discontinuation on the basis of this study may be premature.

Finally, we need to remain cognizant of the proven negative side effects of rosiglitazone—it increases fracture risks in women, precipitates congestive heart failure, increases LDL, and decreases hemoglobin levels. We should consider alternative anti-hyperglycemic agents in selected patients at risk until there are solid data from large randomized control trials with rosiglitazone that pre-empt its use altogether.

References

1. Gerstein HC, Yusuf S, Bosch J, et al. Effect of rosiglitazone on the frequency of diabetes in patients with impaired glucose tolerance or impaired fasting glucose: a randomized controlled trial. Lancet 2006 Sep 23; 368(9547):1096-1105.
2. Kahn SE, Haffner SM, Heise MA, et al; ADOPT Study Group. Glycemic durability of rosiglitazone, metformin, or glyburide monotherapy. N Engl J Med. 2006 Dec 7;355(23):2427-2443.
3. Home PD, Pocock SJ, Beck-Nielsen H, et al. Rosiglitazone evaluated for cardiac outcomes and regulation of glycemia in diabetes (RECORD): study design and protocol. Diabetologia. 2005;48:1726-1735.

Statins and Sepsis in Dialysis Patients

Gupta R, Plantinga LC, Fink NE, et al. Statin use and hospitalization for sepsis in patients with chronic kidney disease. JAMA. 2007 Apr 4;297(13):1455-1464.

Epidemiological data has revealed an increase in the rate of sepsis in the U.S. during the past two decades.1 In individuals with chronic kidney disease who are on dialysis, sepsis is a significant cause of morbidity and mortality. Various studies have looked at risk factors associated with septicemia in patients with chronic kidney disease; however, no preventive treatments have been identified.

Recent research has shown the use of statins has been associated with a decreased rate of sepsis and improved sepsis outcomes. The authors of this study investigated whether statin use may help reduce the incidence of sepsis in patients with chronic kidney disease on dialysis.

This prospective cohort study enrolled 1,041 participants attending dialysis clinics from October 1995 to June 1998, with a follow-up through Jan. 1, 2005. Statin use at baseline was determined by review of medical records. The primary outcome was hospitalization for sepsis, indicated by hospital data from the U.S. Renal Data System (mean follow-up 3.4 years).

The association of statin use and sepsis was assessed using two analyses. A multivariate regression analysis was performed on the entire cohort, and adjustments were made for potential confounders. An analysis was performed on a sub-cohort comparing sepsis rates in statin users with a control group identified through the likelihood of having been prescribed a statin (propensity matching).

There were 303 hospitalizations for sepsis among the 1,041 patients enrolled, with 14% of participants receiving a statin at baseline. The crude incidence rate of sepsis was 41/1,000 patient-years among statin users compared with 110/1,000 patient-years in the control group (p<0.001). The fully adjusted incidence ratio for sepsis among statin users versus nonusers was 0.38, or 62% lower among statin users.

In the propensity-matched subcohort group, there were 54 hospitalizations during follow-up. The relative risk of sepsis was 0.24 (95% confidence interval, 0.11-0.49) for statin users compared with nonusers.

A strong and independent association exists between statin use and reduced incidence of sepsis in chronic kidney disease patients. This association remained statistically significant after controlling for potential confounding. Why the statins might have this effect is not definitively known.

This national study further demonstrates the potential protective effect of statins on the occurrence of sepsis, which has been observed in previous research in a non-renal population. The author mentions that this is the first study to show a strong and significant effect of a medication administered long term on lower rates of sepsis among patients with chronic kidney disease.

Because this is an observational study, it is limited due to lack of randomization. As such, this study cannot prove causality. Further limitations include the assessment of patient and treatment factors at baseline, which can lead to a misclassification of factors that change over time. It is important to point out the study was dependent on U.S. Renal Data System and Medicare data to determine outcome, and the use of their ICD-9 coding information may have resulted in decreased reporting of sepsis.

Still, the relevant results of this investigation warrant further examination of statins and the prevention of sepsis in a prospective randomized trial. TH

Reference

1. Sarnak MJ, Jaber BL. Mortality caused by sepsis in patients with end-stage renal disease compared with the general population. Kidney Int. 2000 Oct;58(4):1758-1764.

Retrospective Study of Symptoms in Post-Discharge Patients

Epstein K, Juarez E, Loya K, et al. Frequency of new or worsening symptoms in the posthospitalization period. J Hosp Med. March/April 2007;2(2):58-68.

As hospital stays shorten and acuity rises, patients often are discharged with complex instructions and discharge plans including home health services, physical therapy, hospice service, antibiotic infusions, and follow-up appointments. The potential for new or progressive symptoms in the days following discharge is an important parameter in assessing whether our planning is safe and effective.

The researchers in this study investigated the post-discharge period using a retrospective analysis of new or worsening symptoms within two to five days of hospital discharge among 15,767 patients surveyed between May 1 and Oct. 31, 2003. Patients were all under the care of hospitalists employed by IPC, a large private hospitalist group based in North Hollywood, Calif. Total discharges from which this cohort was selected numbered 48,236.

Staff with medical backgrounds conducted a scripted survey by phone. Licensed nursing personnel contacted those patients whose answers to initial questions suggested they were at high risk for postdischarge complications. A five-point Likert scale was used so patients could rate their overall health status in addition to specific symptomatology ranging from abdominal pain to bleeding. Other questions targeted pick-up and administration of prescribed medications, insulin regimen adherence, and implementation of home health services.

Among all patients discharged, 32.7% were contacted within two days of discharge. The mean age was 60.1 years, and 57% were female. Ethnicity and socioeconomic status were not reported. Medicare and HMOs were the most common type of insurance. Of the 15,767 patients contacted, 11.9% reported symptoms that were new or worsening since discharge; of this subgroup, 64% had new symptoms whereas 36% had “worse” symptoms.

Women were more likely than men to report new or worsening symptoms, and patients who rated themselves as having a poor health status were more likely to have new or worsening symptoms. Younger patients were less likely to report new or worsening symptoms, particularly younger men. Those with new or worse symptoms were slightly more likely to have made a follow-up appointment but also more likely to have a problem with their medications. Interestingly, there was no correlation between self-rated health status and reported severity of illness based on the diagnosis related group (DRG) score. Patients discharged with a DRG of chest pain were less likely to report symptoms than all other patients.

The authors acknowledge the low response rate (32.7%) relative to the 48,236 discharges during the study period. Logistic challenges, resource limitations, and erroneous contact information precluded successful contact for the remainder of patients. The magnitude of this exclusion effect essentially precludes statistically valid extrapolation to the inception cohort (all discharges). For example, in a sensitivity analysis where all the excluded patients are assumed to have developed new or worsening symptoms, the actual rate overall would have been 71%. If none developed new or worsening symptoms, that rate would be 3.8%. The rate for the inception cohort may or may not approximate the 11.9% found among the studied patients. There is insufficient evidence to determine whether the studied cohort reflects the entire population of discharged patients.

To their credit, no such analysis or interpretation is claimed or intended by the authors, and the information derived from the included cohort nonetheless provides interesting and important descriptive data.

Ethnicity and cultural factors were not taken into consideration. One might postulate that language barriers could affect compliance and symptom reporting. Day-of-the-week and holiday status also were not reported with regard to discharge. It would be interesting and useful to know whether access to pharmacy and other resources varied in this regard and whether symptom reporting was affected by such timing.

In the final analysis, this study suggests hospitalists remain alert to possible problems that might develop during the vulnerable first few days following discharge. It reminds us to advise patients how to receive prompt and knowledgeable medical advice from someone familiar with their hospital care prior to their first scheduled follow-up.

Based on the reported rate of new or worsening symptoms, should a post-discharge clinic be part of hospitalists’ scope of practice, at least for selected patients? Can subsets of patients who would benefit most from such intervention be identified? These and many more questions are raised by this study. We look forward to further research into the best process for ensuring optimal outcomes in the immediate post-discharge period.

Rosiglitazone’s Effect on MI Risk in Diabetes Patients

Nissen SE, Wolski K. Effect of rosiglitazone on the risk of myocardial infarction and death from cardiovascular causes. N Engl J Med. 2007 June 14;356(24):2457-2471.

Cardiovascular causes account for more than 65% of deaths in diabetic patients. Rosiglitazone—a thiazolidinedione-class drug—has been broadly used in diabetes, but its effect on cardiovascular morbidity and mortality has not been conclusively determined. The authors initiated this meta-analysis to determine the effect of rosiglitazone on the risk of myocardial infarction (MI) and death from cardiovascular causes in diabetics.

The meta-analysis included 42 trials from three data sources. Forty trials were obtained from the Food and Drug Administration (FDA) Web site and the GlaxoSmithKline clinical trials registry. The third data source comprised two recent large, well-known trials: the Diabetes Reduction Assessment with Ramipril and Rosiglitazone Medication (DREAM) and the A Diabetes Outcome Prevention Trial (ADOPT).1-2 The authors’ inclusion criteria were a study with a duration of more than 24 weeks, the use of a randomized control group not receiving rosiglitazone (placebo or comparator drug), and the availability of outcome data for MI and death from cardiovascular causes.

The studies included 15,560 patients randomly assigned to regimens that included rosiglitazone and 12,283 patients to comparator groups that did not include rosiglitazone.

The authors reviewed the data summaries of the 42 trials and tabulated adverse events (not reported as outcomes) of MI and death from cardiovascular causes. Hazard ratios could not be calculated since time-to-event data were lacking. Summary data also precluded the ability to determine whether the same patient suffered both an MI and death from cardiovascular causes.

Results of the authors’ statistical analyses included odds ratios and 95% confidence intervals to assess the risk associated with the rosiglitazone group as well as the subgroups of metformin, sulfonylurea, insulin, and placebo versus rosiglitazone.

The authors tabulated 86 MIs and 39 unadjudicated deaths from cardiovascular causes in the rosiglitazone group, and 72 MIs plus 22 deaths from cardiovascular causes in the control group.

The main conclusion was that rosiglitazone was associated with a statistically significant increase in the risk of MI (odds ratio 1.43, 95% confidence interval 1.03 to 1.98, p=0.03), but was not associated with a statistically significant increase in the risk of death from cardiovascular causes (odds ratio 1.64, 95% confidence interval 0.98 to 2.74, p=0.06).

Additionally, there were no statistical differences between rosiglitazone versus placebo or the individual antidiabetics in the subanalyses.

The authors have recognized the following major limitations in this meta-analysis:

• The low rate of MI is 0.55% (86 of 15,560 cases) in the rosiglitazone group and 0.59% (72 of 12,283 cases) in the control group. The odds ratio of 1.43 was statistically significant in the rosiglitazone group, although the event rate was higher in the control group. The risk of cardiovascular death was not significant, though a trend toward a higher death rate is noted;
• The lack of source data did not allow the use of time event analysis including hazard ratios;
• The definition of MI was unavailable; and
• MI and cardiovascular events were recorded in the trials as adverse events, not outcomes. Therefore, deaths from the latter were unadjudicated.

The authors suggested that the potential mechanism for increased MI in the rosiglitazone group could be its known effects on increasing low-density lipoproteins (LDL), precipitating congestive heart failure and reducing hemoglobin levels.

Rosiglitazone is one of two peroxisome proliferation activated receptor y (PPAR-y) agonists licensed for use in the United States; the other is pioglitazone. The third drug was troglitazone; it was taken off the market in March of 2000 due to hepatotoxicity.

The PPAR-y agonists decrease plasma glycemia by increasing insulin sensitivity in the peripheral tissues. These drugs have complex physiologic effects in activating and suppressing multiple genes, with most target genes being unknown. The observed side effects with rosiglitazone are not necessarily a class effect. Pioglitazone showed a trend toward reducing triglycerides and cardiovascular events, including MI and CVA, in a prospective, randomized trial called Prospective Pioglitazone Clinical Trial in Macrovascular Events (PROACTIVE).

This meta-analysis precipitated an interim analysis of the ongoing Rosiglitazone Evaluated for Cardiovascular Outcomes and Regulation of Glycemia in Diabetes (RECORD) trial.3 The RECORD trial is a randomized, open-label, multicenter, non-inferiority trial of 4,427 patients; 2,220 received add-on rosiglitazone, and 2,227 received a combination of metformin plus sulfonylurea (control group). The primary end point was hospitalization or death from cardiovascular causes. Interim findings were inconclusive for the rosiglitazone group. There was also no evidence of any increase in death from cardiovascular causes or all causes. However, rosiglitazone was found to be associated with an increased risk of congestive heart failure. The data were insufficient to determine whether the drug was associated with increased MI risk.

This important meta-analysis raises concerns about the association of rosiglitazone with cardiovascular events—but do not consider it definitive. For now, patients with comparable alternatives to rosiglitazone (indeed all patients on this medication) should be advised of the undetermined safety concerns. For those who consider rosiglitazone a compelling choice, abrupt discontinuation on the basis of this study may be premature.

Finally, we need to remain cognizant of the proven negative side effects of rosiglitazone—it increases fracture risks in women, precipitates congestive heart failure, increases LDL, and decreases hemoglobin levels. We should consider alternative anti-hyperglycemic agents in selected patients at risk until there are solid data from large randomized control trials with rosiglitazone that pre-empt its use altogether.

References

1. Gerstein HC, Yusuf S, Bosch J, et al. Effect of rosiglitazone on the frequency of diabetes in patients with impaired glucose tolerance or impaired fasting glucose: a randomized controlled trial. Lancet 2006 Sep 23; 368(9547):1096-1105.
2. Kahn SE, Haffner SM, Heise MA, et al; ADOPT Study Group. Glycemic durability of rosiglitazone, metformin, or glyburide monotherapy. N Engl J Med. 2006 Dec 7;355(23):2427-2443.
3. Home PD, Pocock SJ, Beck-Nielsen H, et al. Rosiglitazone evaluated for cardiac outcomes and regulation of glycemia in diabetes (RECORD): study design and protocol. Diabetologia. 2005;48:1726-1735.

Statins and Sepsis in Dialysis Patients

Gupta R, Plantinga LC, Fink NE, et al. Statin use and hospitalization for sepsis in patients with chronic kidney disease. JAMA. 2007 Apr 4;297(13):1455-1464.

Epidemiological data has revealed an increase in the rate of sepsis in the U.S. during the past two decades.1 In individuals with chronic kidney disease who are on dialysis, sepsis is a significant cause of morbidity and mortality. Various studies have looked at risk factors associated with septicemia in patients with chronic kidney disease; however, no preventive treatments have been identified.

Recent research has shown the use of statins has been associated with a decreased rate of sepsis and improved sepsis outcomes. The authors of this study investigated whether statin use may help reduce the incidence of sepsis in patients with chronic kidney disease on dialysis.

This prospective cohort study enrolled 1,041 participants attending dialysis clinics from October 1995 to June 1998, with a follow-up through Jan. 1, 2005. Statin use at baseline was determined by review of medical records. The primary outcome was hospitalization for sepsis, indicated by hospital data from the U.S. Renal Data System (mean follow-up 3.4 years).

The association of statin use and sepsis was assessed using two analyses. A multivariate regression analysis was performed on the entire cohort, and adjustments were made for potential confounders. An analysis was performed on a sub-cohort comparing sepsis rates in statin users with a control group identified through the likelihood of having been prescribed a statin (propensity matching).

There were 303 hospitalizations for sepsis among the 1,041 patients enrolled, with 14% of participants receiving a statin at baseline. The crude incidence rate of sepsis was 41/1,000 patient-years among statin users compared with 110/1,000 patient-years in the control group (p<0.001). The fully adjusted incidence ratio for sepsis among statin users versus nonusers was 0.38, or 62% lower among statin users.

In the propensity-matched subcohort group, there were 54 hospitalizations during follow-up. The relative risk of sepsis was 0.24 (95% confidence interval, 0.11-0.49) for statin users compared with nonusers.

A strong and independent association exists between statin use and reduced incidence of sepsis in chronic kidney disease patients. This association remained statistically significant after controlling for potential confounding. Why the statins might have this effect is not definitively known.

This national study further demonstrates the potential protective effect of statins on the occurrence of sepsis, which has been observed in previous research in a non-renal population. The author mentions that this is the first study to show a strong and significant effect of a medication administered long term on lower rates of sepsis among patients with chronic kidney disease.

Because this is an observational study, it is limited due to lack of randomization. As such, this study cannot prove causality. Further limitations include the assessment of patient and treatment factors at baseline, which can lead to a misclassification of factors that change over time. It is important to point out the study was dependent on U.S. Renal Data System and Medicare data to determine outcome, and the use of their ICD-9 coding information may have resulted in decreased reporting of sepsis.

Still, the relevant results of this investigation warrant further examination of statins and the prevention of sepsis in a prospective randomized trial. TH

Reference

1. Sarnak MJ, Jaber BL. Mortality caused by sepsis in patients with end-stage renal disease compared with the general population. Kidney Int. 2000 Oct;58(4):1758-1764.

Retrospective Study of Symptoms in Post-Discharge Patients

Epstein K, Juarez E, Loya K, et al. Frequency of new or worsening symptoms in the posthospitalization period. J Hosp Med. March/April 2007;2(2):58-68.

As hospital stays shorten and acuity rises, patients often are discharged with complex instructions and discharge plans including home health services, physical therapy, hospice service, antibiotic infusions, and follow-up appointments. The potential for new or progressive symptoms in the days following discharge is an important parameter in assessing whether our planning is safe and effective.

The researchers in this study investigated the post-discharge period using a retrospective analysis of new or worsening symptoms within two to five days of hospital discharge among 15,767 patients surveyed between May 1 and Oct. 31, 2003. Patients were all under the care of hospitalists employed by IPC, a large private hospitalist group based in North Hollywood, Calif. Total discharges from which this cohort was selected numbered 48,236.

Staff with medical backgrounds conducted a scripted survey by phone. Licensed nursing personnel contacted those patients whose answers to initial questions suggested they were at high risk for postdischarge complications. A five-point Likert scale was used so patients could rate their overall health status in addition to specific symptomatology ranging from abdominal pain to bleeding. Other questions targeted pick-up and administration of prescribed medications, insulin regimen adherence, and implementation of home health services.

Among all patients discharged, 32.7% were contacted within two days of discharge. The mean age was 60.1 years, and 57% were female. Ethnicity and socioeconomic status were not reported. Medicare and HMOs were the most common type of insurance. Of the 15,767 patients contacted, 11.9% reported symptoms that were new or worsening since discharge; of this subgroup, 64% had new symptoms whereas 36% had “worse” symptoms.

Women were more likely than men to report new or worsening symptoms, and patients who rated themselves as having a poor health status were more likely to have new or worsening symptoms. Younger patients were less likely to report new or worsening symptoms, particularly younger men. Those with new or worse symptoms were slightly more likely to have made a follow-up appointment but also more likely to have a problem with their medications. Interestingly, there was no correlation between self-rated health status and reported severity of illness based on the diagnosis related group (DRG) score. Patients discharged with a DRG of chest pain were less likely to report symptoms than all other patients.

The authors acknowledge the low response rate (32.7%) relative to the 48,236 discharges during the study period. Logistic challenges, resource limitations, and erroneous contact information precluded successful contact for the remainder of patients. The magnitude of this exclusion effect essentially precludes statistically valid extrapolation to the inception cohort (all discharges). For example, in a sensitivity analysis where all the excluded patients are assumed to have developed new or worsening symptoms, the actual rate overall would have been 71%. If none developed new or worsening symptoms, that rate would be 3.8%. The rate for the inception cohort may or may not approximate the 11.9% found among the studied patients. There is insufficient evidence to determine whether the studied cohort reflects the entire population of discharged patients.

To their credit, no such analysis or interpretation is claimed or intended by the authors, and the information derived from the included cohort nonetheless provides interesting and important descriptive data.

Ethnicity and cultural factors were not taken into consideration. One might postulate that language barriers could affect compliance and symptom reporting. Day-of-the-week and holiday status also were not reported with regard to discharge. It would be interesting and useful to know whether access to pharmacy and other resources varied in this regard and whether symptom reporting was affected by such timing.

In the final analysis, this study suggests hospitalists remain alert to possible problems that might develop during the vulnerable first few days following discharge. It reminds us to advise patients how to receive prompt and knowledgeable medical advice from someone familiar with their hospital care prior to their first scheduled follow-up.

Based on the reported rate of new or worsening symptoms, should a post-discharge clinic be part of hospitalists’ scope of practice, at least for selected patients? Can subsets of patients who would benefit most from such intervention be identified? These and many more questions are raised by this study. We look forward to further research into the best process for ensuring optimal outcomes in the immediate post-discharge period.

Rosiglitazone’s Effect on MI Risk in Diabetes Patients

Nissen SE, Wolski K. Effect of rosiglitazone on the risk of myocardial infarction and death from cardiovascular causes. N Engl J Med. 2007 June 14;356(24):2457-2471.

Cardiovascular causes account for more than 65% of deaths in diabetic patients. Rosiglitazone—a thiazolidinedione-class drug—has been broadly used in diabetes, but its effect on cardiovascular morbidity and mortality has not been conclusively determined. The authors initiated this meta-analysis to determine the effect of rosiglitazone on the risk of myocardial infarction (MI) and death from cardiovascular causes in diabetics.

The meta-analysis included 42 trials from three data sources. Forty trials were obtained from the Food and Drug Administration (FDA) Web site and the GlaxoSmithKline clinical trials registry. The third data source comprised two recent large, well-known trials: the Diabetes Reduction Assessment with Ramipril and Rosiglitazone Medication (DREAM) and the A Diabetes Outcome Prevention Trial (ADOPT).1-2 The authors’ inclusion criteria were a study with a duration of more than 24 weeks, the use of a randomized control group not receiving rosiglitazone (placebo or comparator drug), and the availability of outcome data for MI and death from cardiovascular causes.

The studies included 15,560 patients randomly assigned to regimens that included rosiglitazone and 12,283 patients to comparator groups that did not include rosiglitazone.

The authors reviewed the data summaries of the 42 trials and tabulated adverse events (not reported as outcomes) of MI and death from cardiovascular causes. Hazard ratios could not be calculated since time-to-event data were lacking. Summary data also precluded the ability to determine whether the same patient suffered both an MI and death from cardiovascular causes.

Results of the authors’ statistical analyses included odds ratios and 95% confidence intervals to assess the risk associated with the rosiglitazone group as well as the subgroups of metformin, sulfonylurea, insulin, and placebo versus rosiglitazone.

The authors tabulated 86 MIs and 39 unadjudicated deaths from cardiovascular causes in the rosiglitazone group, and 72 MIs plus 22 deaths from cardiovascular causes in the control group.

The main conclusion was that rosiglitazone was associated with a statistically significant increase in the risk of MI (odds ratio 1.43, 95% confidence interval 1.03 to 1.98, p=0.03), but was not associated with a statistically significant increase in the risk of death from cardiovascular causes (odds ratio 1.64, 95% confidence interval 0.98 to 2.74, p=0.06).

Additionally, there were no statistical differences between rosiglitazone versus placebo or the individual antidiabetics in the subanalyses.

The authors have recognized the following major limitations in this meta-analysis:

• The low rate of MI is 0.55% (86 of 15,560 cases) in the rosiglitazone group and 0.59% (72 of 12,283 cases) in the control group. The odds ratio of 1.43 was statistically significant in the rosiglitazone group, although the event rate was higher in the control group. The risk of cardiovascular death was not significant, though a trend toward a higher death rate is noted;
• The lack of source data did not allow the use of time event analysis including hazard ratios;
• The definition of MI was unavailable; and
• MI and cardiovascular events were recorded in the trials as adverse events, not outcomes. Therefore, deaths from the latter were unadjudicated.

The authors suggested that the potential mechanism for increased MI in the rosiglitazone group could be its known effects on increasing low-density lipoproteins (LDL), precipitating congestive heart failure and reducing hemoglobin levels.

Rosiglitazone is one of two peroxisome proliferation activated receptor y (PPAR-y) agonists licensed for use in the United States; the other is pioglitazone. The third drug was troglitazone; it was taken off the market in March of 2000 due to hepatotoxicity.

The PPAR-y agonists decrease plasma glycemia by increasing insulin sensitivity in the peripheral tissues. These drugs have complex physiologic effects in activating and suppressing multiple genes, with most target genes being unknown. The observed side effects with rosiglitazone are not necessarily a class effect. Pioglitazone showed a trend toward reducing triglycerides and cardiovascular events, including MI and CVA, in a prospective, randomized trial called Prospective Pioglitazone Clinical Trial in Macrovascular Events (PROACTIVE).

This meta-analysis precipitated an interim analysis of the ongoing Rosiglitazone Evaluated for Cardiovascular Outcomes and Regulation of Glycemia in Diabetes (RECORD) trial.3 The RECORD trial is a randomized, open-label, multicenter, non-inferiority trial of 4,427 patients; 2,220 received add-on rosiglitazone, and 2,227 received a combination of metformin plus sulfonylurea (control group). The primary end point was hospitalization or death from cardiovascular causes. Interim findings were inconclusive for the rosiglitazone group. There was also no evidence of any increase in death from cardiovascular causes or all causes. However, rosiglitazone was found to be associated with an increased risk of congestive heart failure. The data were insufficient to determine whether the drug was associated with increased MI risk.

This important meta-analysis raises concerns about the association of rosiglitazone with cardiovascular events—but do not consider it definitive. For now, patients with comparable alternatives to rosiglitazone (indeed all patients on this medication) should be advised of the undetermined safety concerns. For those who consider rosiglitazone a compelling choice, abrupt discontinuation on the basis of this study may be premature.

Finally, we need to remain cognizant of the proven negative side effects of rosiglitazone—it increases fracture risks in women, precipitates congestive heart failure, increases LDL, and decreases hemoglobin levels. We should consider alternative anti-hyperglycemic agents in selected patients at risk until there are solid data from large randomized control trials with rosiglitazone that pre-empt its use altogether.

References

1. Gerstein HC, Yusuf S, Bosch J, et al. Effect of rosiglitazone on the frequency of diabetes in patients with impaired glucose tolerance or impaired fasting glucose: a randomized controlled trial. Lancet 2006 Sep 23; 368(9547):1096-1105.
2. Kahn SE, Haffner SM, Heise MA, et al; ADOPT Study Group. Glycemic durability of rosiglitazone, metformin, or glyburide monotherapy. N Engl J Med. 2006 Dec 7;355(23):2427-2443.
3. Home PD, Pocock SJ, Beck-Nielsen H, et al. Rosiglitazone evaluated for cardiac outcomes and regulation of glycemia in diabetes (RECORD): study design and protocol. Diabetologia. 2005;48:1726-1735.

Statins and Sepsis in Dialysis Patients

Gupta R, Plantinga LC, Fink NE, et al. Statin use and hospitalization for sepsis in patients with chronic kidney disease. JAMA. 2007 Apr 4;297(13):1455-1464.

Epidemiological data has revealed an increase in the rate of sepsis in the U.S. during the past two decades.1 In individuals with chronic kidney disease who are on dialysis, sepsis is a significant cause of morbidity and mortality. Various studies have looked at risk factors associated with septicemia in patients with chronic kidney disease; however, no preventive treatments have been identified.

Recent research has shown the use of statins has been associated with a decreased rate of sepsis and improved sepsis outcomes. The authors of this study investigated whether statin use may help reduce the incidence of sepsis in patients with chronic kidney disease on dialysis.

This prospective cohort study enrolled 1,041 participants attending dialysis clinics from October 1995 to June 1998, with a follow-up through Jan. 1, 2005. Statin use at baseline was determined by review of medical records. The primary outcome was hospitalization for sepsis, indicated by hospital data from the U.S. Renal Data System (mean follow-up 3.4 years).

The association of statin use and sepsis was assessed using two analyses. A multivariate regression analysis was performed on the entire cohort, and adjustments were made for potential confounders. An analysis was performed on a sub-cohort comparing sepsis rates in statin users with a control group identified through the likelihood of having been prescribed a statin (propensity matching).

There were 303 hospitalizations for sepsis among the 1,041 patients enrolled, with 14% of participants receiving a statin at baseline. The crude incidence rate of sepsis was 41/1,000 patient-years among statin users compared with 110/1,000 patient-years in the control group (p<0.001). The fully adjusted incidence ratio for sepsis among statin users versus nonusers was 0.38, or 62% lower among statin users.

In the propensity-matched subcohort group, there were 54 hospitalizations during follow-up. The relative risk of sepsis was 0.24 (95% confidence interval, 0.11-0.49) for statin users compared with nonusers.

A strong and independent association exists between statin use and reduced incidence of sepsis in chronic kidney disease patients. This association remained statistically significant after controlling for potential confounding. Why the statins might have this effect is not definitively known.

This national study further demonstrates the potential protective effect of statins on the occurrence of sepsis, which has been observed in previous research in a non-renal population. The author mentions that this is the first study to show a strong and significant effect of a medication administered long term on lower rates of sepsis among patients with chronic kidney disease.

Because this is an observational study, it is limited due to lack of randomization. As such, this study cannot prove causality. Further limitations include the assessment of patient and treatment factors at baseline, which can lead to a misclassification of factors that change over time. It is important to point out the study was dependent on U.S. Renal Data System and Medicare data to determine outcome, and the use of their ICD-9 coding information may have resulted in decreased reporting of sepsis.

Still, the relevant results of this investigation warrant further examination of statins and the prevention of sepsis in a prospective randomized trial. TH

Reference

1. Sarnak MJ, Jaber BL. Mortality caused by sepsis in patients with end-stage renal disease compared with the general population. Kidney Int. 2000 Oct;58(4):1758-1764.

As I walked around our office during the week after this year’s SHM Annual Meeting, there was a simple question on the minds of many: What’s next?

After the 12-month planning of “Hospital Medicine 2007”—which culminated in a week away from family, getting out of bed before 5 a.m., and falling asleep after midnight—I guess “What’s next?” is a pretty reasonable question. It’s not at all a surprising question considering the “blood, sweat, and tears” so many volunteer leaders and staff gave to put on an event befitting the fastest-growing specialty in modern healthcare.

“What’s next?” is a fair question for our members to ask of us as well. After all, like so many other organizations, much of what SHM does is designed to come on line, or culminate, during the annual meeting.

I wanted to use this month’s column to give you a small glimpse inside our answer to this simple—yet powerful—question.

One of the surprise stories from “Hospital Medicine 2007” was the success of our Annual Meeting Blog. Over the course of three days, several hospital medicine leaders, including Bob Wachter, MD, shared their experiences—in real time—from Dallas. Augmenting the posts from these contributors were audio podcast interviews with notables that included keynote speaker David Brailer, MD, the first national coordinator for health information technology with the Department of Health and Human Services.

More than 1,000 people visited SHM’s first foray into the blogosphere. Even more exciting is that the blog had hits from hospitalists unable to join us in Dallas.

It used to be that we would say that the biggest meeting in hospital medicine took place each year at the site of the SHM Annual Meeting. With the introduction of the blog, we can now say that is no longer the case. The biggest meeting takes place in more than one city, in more than one hospital, with the geographic location of the SHM Annual Meeting just the hub.

The blog is just the beginning of the answer to the question “What’s next?”

During the coming year, we will use our blogging success as a building block to bringing what many call “new media” squarely into the framework of SHM. You are starting to see the first steps of that effort with the redesign of our homepage, www.hospitalmedicine.org.

To us, new media serves several purposes:

• Inform: The blog showed us a powerful way to deliver real-time news without the delay some publications require;
• Educate: We’re working on creating Webinars—audio conferences coupled with Internet presentations—that will bring education directly to you, at your institution, throughout the year;
• Connect: Through online discussions with thought leaders, including authors from The Hospitalist, we want to celebrate the fact that the most powerful connection we can facilitate is from physician to physician; and
• Differentiate: By bringing these elements together, from blogs and podcasts to Webinars and new online resources, we want to make the question “Why SHM?” one of the easiest you’ll ever have to answer.

What’s next? It’s an interesting question. To us, a major part of the answer is the same it’s always been: to continue innovating by building on our successes and being the group committed to blazing new trails that are focused squarely, and solely, on delivering benefit to our members and the hospital medicine movement.

As I walked around our office during the week after this year’s SHM Annual Meeting, there was a simple question on the minds of many: What’s next?

After the 12-month planning of “Hospital Medicine 2007”—which culminated in a week away from family, getting out of bed before 5 a.m., and falling asleep after midnight—I guess “What’s next?” is a pretty reasonable question. It’s not at all a surprising question considering the “blood, sweat, and tears” so many volunteer leaders and staff gave to put on an event befitting the fastest-growing specialty in modern healthcare.

“What’s next?” is a fair question for our members to ask of us as well. After all, like so many other organizations, much of what SHM does is designed to come on line, or culminate, during the annual meeting.

I wanted to use this month’s column to give you a small glimpse inside our answer to this simple—yet powerful—question.

One of the surprise stories from “Hospital Medicine 2007” was the success of our Annual Meeting Blog. Over the course of three days, several hospital medicine leaders, including Bob Wachter, MD, shared their experiences—in real time—from Dallas. Augmenting the posts from these contributors were audio podcast interviews with notables that included keynote speaker David Brailer, MD, the first national coordinator for health information technology with the Department of Health and Human Services.

More than 1,000 people visited SHM’s first foray into the blogosphere. Even more exciting is that the blog had hits from hospitalists unable to join us in Dallas.

It used to be that we would say that the biggest meeting in hospital medicine took place each year at the site of the SHM Annual Meeting. With the introduction of the blog, we can now say that is no longer the case. The biggest meeting takes place in more than one city, in more than one hospital, with the geographic location of the SHM Annual Meeting just the hub.

The blog is just the beginning of the answer to the question “What’s next?”

During the coming year, we will use our blogging success as a building block to bringing what many call “new media” squarely into the framework of SHM. You are starting to see the first steps of that effort with the redesign of our homepage, www.hospitalmedicine.org.

To us, new media serves several purposes:

• Inform: The blog showed us a powerful way to deliver real-time news without the delay some publications require;
• Educate: We’re working on creating Webinars—audio conferences coupled with Internet presentations—that will bring education directly to you, at your institution, throughout the year;
• Connect: Through online discussions with thought leaders, including authors from The Hospitalist, we want to celebrate the fact that the most powerful connection we can facilitate is from physician to physician; and
• Differentiate: By bringing these elements together, from blogs and podcasts to Webinars and new online resources, we want to make the question “Why SHM?” one of the easiest you’ll ever have to answer.

What’s next? It’s an interesting question. To us, a major part of the answer is the same it’s always been: to continue innovating by building on our successes and being the group committed to blazing new trails that are focused squarely, and solely, on delivering benefit to our members and the hospital medicine movement.

As I walked around our office during the week after this year’s SHM Annual Meeting, there was a simple question on the minds of many: What’s next?

After the 12-month planning of “Hospital Medicine 2007”—which culminated in a week away from family, getting out of bed before 5 a.m., and falling asleep after midnight—I guess “What’s next?” is a pretty reasonable question. It’s not at all a surprising question considering the “blood, sweat, and tears” so many volunteer leaders and staff gave to put on an event befitting the fastest-growing specialty in modern healthcare.

“What’s next?” is a fair question for our members to ask of us as well. After all, like so many other organizations, much of what SHM does is designed to come on line, or culminate, during the annual meeting.

I wanted to use this month’s column to give you a small glimpse inside our answer to this simple—yet powerful—question.

One of the surprise stories from “Hospital Medicine 2007” was the success of our Annual Meeting Blog. Over the course of three days, several hospital medicine leaders, including Bob Wachter, MD, shared their experiences—in real time—from Dallas. Augmenting the posts from these contributors were audio podcast interviews with notables that included keynote speaker David Brailer, MD, the first national coordinator for health information technology with the Department of Health and Human Services.

More than 1,000 people visited SHM’s first foray into the blogosphere. Even more exciting is that the blog had hits from hospitalists unable to join us in Dallas.

It used to be that we would say that the biggest meeting in hospital medicine took place each year at the site of the SHM Annual Meeting. With the introduction of the blog, we can now say that is no longer the case. The biggest meeting takes place in more than one city, in more than one hospital, with the geographic location of the SHM Annual Meeting just the hub.

The blog is just the beginning of the answer to the question “What’s next?”

During the coming year, we will use our blogging success as a building block to bringing what many call “new media” squarely into the framework of SHM. You are starting to see the first steps of that effort with the redesign of our homepage, www.hospitalmedicine.org.

To us, new media serves several purposes:

• Inform: The blog showed us a powerful way to deliver real-time news without the delay some publications require;
• Educate: We’re working on creating Webinars—audio conferences coupled with Internet presentations—that will bring education directly to you, at your institution, throughout the year;
• Connect: Through online discussions with thought leaders, including authors from The Hospitalist, we want to celebrate the fact that the most powerful connection we can facilitate is from physician to physician; and
• Differentiate: By bringing these elements together, from blogs and podcasts to Webinars and new online resources, we want to make the question “Why SHM?” one of the easiest you’ll ever have to answer.

What’s next? It’s an interesting question. To us, a major part of the answer is the same it’s always been: to continue innovating by building on our successes and being the group committed to blazing new trails that are focused squarely, and solely, on delivering benefit to our members and the hospital medicine movement.

This is the third in a series of articles on the four pillars of career satisfaction in hospital medicine.

How much does your satisfaction with your job rely on your compensation level? What about your sense of being appreciated for what you do each day?

Many hospitalists would say the latter could be a key factor in their happiness with their career. This is confirmed in a new white paper from SHM, “A Challenge for a New Specialty: A White Paper on Hospitalist Career Satisfaction” (available online at www.hospitalmedicine.org). This document, created by SHM’s Career Satisfaction Task Force (CSTF), can be used by hospitalists and hospital medicine practices as a toolkit for improving or ensuring job satisfaction. It outlines the four pillars of career satisfaction, the third of which is reward/recognition.

The Third Pillar

The reward/recognition pillar includes not just financial rewards but also social rewards (appreciation by your colleagues, leaders, patients, and family) and intrinsic rewards (healing patients or working efficiently and productively).

Achieving on-the-job recognition requires practicing high-quality medicine, communicating this to all the groups above, and participating in professional development and leadership. It also entails building relationships with peers and allied health professionals, hospital executives, patients, and the community.

“Reward and recognition ties in a lot with the other pillars—especially community,” says CSTF member Adrienne Bennett, MD, PhD, Ohio State University Medical Center, Columbus. “Part of what makes or breaks any hospitalist job is the group you work with and how you get along. This has to do with how you’re viewed and how you’re rewarded and supported.”

The classic dichotomy of values in hospital medicine is salary versus quality of life. Some groups offer higher salaries with heavy workloads and/or many shifts, and others value time over money. But there are additional values that affect reward and recognition. For example, let’s say you want to build a career or reputation in patient safety and quality of care but you work for a hospital medicine group focused mainly on high-volume patient care that is not engaged in quality improvement work. Your group may not value or reward your efforts. This can lead to job dissatisfaction.

“Make sure the group you join has a culture that shares or at least respects and supports your other career interests,” advises Dr. Bennett. “Working with a group where you’re a good fit and that supports your career aspirations is the most important aspect of career satisfaction.”

An Example of Reward Issues

To illustrate how reward/recognition works, here’s a fictional example of a hospitalist faced with a decision regarding her career:

“I’m ready to find my first job in hospital medicine, and my husband just accepted a pulmonary fellowship at a Midwestern university hospital. There are five hospital medicine groups in the area to choose from. I have to decide which I’d prefer to work for. My main priority is that I want to be ‘a name’ in hospital medicine—I want a chance to build a good reputation nationally.”

According to the white paper, a hospitalist in this position should take several steps to ensure career satisfaction:

Step 1: Assess your choices. Use the series of questions provided in the white paper to compare programs, including compensation and benefits.

“This hospitalist seems to want something more out of her work than just the rewards that come from taking excellent care of her patients,” observes Dr. Bennett. “When she’s interviewing, she needs to ask very carefully about opportunities for leadership development and for building her local reputation, which is the first step toward larger recognition. She needs to find out if the group supports and values work on hospital and/or medical association committees. Many community-based groups do support this.”

Step 2: Once you’re hired, set short- and long-term performance goals. Understand what you want to be recognized for, and outline what you want to accomplish—whether it’s a research project, a leadership role on a committee, or simply a standard of patient care you set for yourself.

Step 3: Participate in SHM chapter meetings. Network with physicians from other hospital medicine groups, get involved, and make a name for yourself.

How Your Rewards Stack up

Whether you’re questioning the compensation package at your long-term hospitalist position or weighing a decision on taking a new job, you’ll turn to available benchmark data on hospital medicine.

“There are a lot ways that benchmarks help and hurt,” warns Dr. Bennett. “Some of it isn’t very good because it’s based on very small numbers. If you’re dealing with an employer that relies on data [for compensation levels], it’s important to know what data they’re using. A reliable employer should share that information. Even the SHM benchmark data—which is probably the best we have, since it’s based on several thousand practicing hospitalists in a variety of settings—can’t always tell you how your job compares.”

Many variations within groups and individual jobs make it hard to compare positions side by side. Differentiating factors include salary and other compensation factors, patient load, shifts and schedule (including nights and weekends), and job responsibilities.

“Sometimes you can use the number of work [relative value units] RVUs to compare workloads,” Dr. Bennett suggests.

As with all the pillars of career satisfaction, the rewards and recognitions that come with your job must be measured against what other hospitalist positions offer—but more importantly against your values and priorities. TH

Jane Jerrard has written for The Hospitalist since 2005.

This is the third in a series of articles on the four pillars of career satisfaction in hospital medicine.

How much does your satisfaction with your job rely on your compensation level? What about your sense of being appreciated for what you do each day?

Many hospitalists would say the latter could be a key factor in their happiness with their career. This is confirmed in a new white paper from SHM, “A Challenge for a New Specialty: A White Paper on Hospitalist Career Satisfaction” (available online at www.hospitalmedicine.org). This document, created by SHM’s Career Satisfaction Task Force (CSTF), can be used by hospitalists and hospital medicine practices as a toolkit for improving or ensuring job satisfaction. It outlines the four pillars of career satisfaction, the third of which is reward/recognition.

The Third Pillar

The reward/recognition pillar includes not just financial rewards but also social rewards (appreciation by your colleagues, leaders, patients, and family) and intrinsic rewards (healing patients or working efficiently and productively).

Achieving on-the-job recognition requires practicing high-quality medicine, communicating this to all the groups above, and participating in professional development and leadership. It also entails building relationships with peers and allied health professionals, hospital executives, patients, and the community.

“Reward and recognition ties in a lot with the other pillars—especially community,” says CSTF member Adrienne Bennett, MD, PhD, Ohio State University Medical Center, Columbus. “Part of what makes or breaks any hospitalist job is the group you work with and how you get along. This has to do with how you’re viewed and how you’re rewarded and supported.”

The classic dichotomy of values in hospital medicine is salary versus quality of life. Some groups offer higher salaries with heavy workloads and/or many shifts, and others value time over money. But there are additional values that affect reward and recognition. For example, let’s say you want to build a career or reputation in patient safety and quality of care but you work for a hospital medicine group focused mainly on high-volume patient care that is not engaged in quality improvement work. Your group may not value or reward your efforts. This can lead to job dissatisfaction.

“Make sure the group you join has a culture that shares or at least respects and supports your other career interests,” advises Dr. Bennett. “Working with a group where you’re a good fit and that supports your career aspirations is the most important aspect of career satisfaction.”

An Example of Reward Issues

To illustrate how reward/recognition works, here’s a fictional example of a hospitalist faced with a decision regarding her career:

“I’m ready to find my first job in hospital medicine, and my husband just accepted a pulmonary fellowship at a Midwestern university hospital. There are five hospital medicine groups in the area to choose from. I have to decide which I’d prefer to work for. My main priority is that I want to be ‘a name’ in hospital medicine—I want a chance to build a good reputation nationally.”

According to the white paper, a hospitalist in this position should take several steps to ensure career satisfaction:

Step 1: Assess your choices. Use the series of questions provided in the white paper to compare programs, including compensation and benefits.

“This hospitalist seems to want something more out of her work than just the rewards that come from taking excellent care of her patients,” observes Dr. Bennett. “When she’s interviewing, she needs to ask very carefully about opportunities for leadership development and for building her local reputation, which is the first step toward larger recognition. She needs to find out if the group supports and values work on hospital and/or medical association committees. Many community-based groups do support this.”

Step 2: Once you’re hired, set short- and long-term performance goals. Understand what you want to be recognized for, and outline what you want to accomplish—whether it’s a research project, a leadership role on a committee, or simply a standard of patient care you set for yourself.

Step 3: Participate in SHM chapter meetings. Network with physicians from other hospital medicine groups, get involved, and make a name for yourself.

How Your Rewards Stack up

Whether you’re questioning the compensation package at your long-term hospitalist position or weighing a decision on taking a new job, you’ll turn to available benchmark data on hospital medicine.

“There are a lot ways that benchmarks help and hurt,” warns Dr. Bennett. “Some of it isn’t very good because it’s based on very small numbers. If you’re dealing with an employer that relies on data [for compensation levels], it’s important to know what data they’re using. A reliable employer should share that information. Even the SHM benchmark data—which is probably the best we have, since it’s based on several thousand practicing hospitalists in a variety of settings—can’t always tell you how your job compares.”

Many variations within groups and individual jobs make it hard to compare positions side by side. Differentiating factors include salary and other compensation factors, patient load, shifts and schedule (including nights and weekends), and job responsibilities.

“Sometimes you can use the number of work [relative value units] RVUs to compare workloads,” Dr. Bennett suggests.

As with all the pillars of career satisfaction, the rewards and recognitions that come with your job must be measured against what other hospitalist positions offer—but more importantly against your values and priorities. TH

Jane Jerrard has written for The Hospitalist since 2005.

This is the third in a series of articles on the four pillars of career satisfaction in hospital medicine.

How much does your satisfaction with your job rely on your compensation level? What about your sense of being appreciated for what you do each day?

Many hospitalists would say the latter could be a key factor in their happiness with their career. This is confirmed in a new white paper from SHM, “A Challenge for a New Specialty: A White Paper on Hospitalist Career Satisfaction” (available online at www.hospitalmedicine.org). This document, created by SHM’s Career Satisfaction Task Force (CSTF), can be used by hospitalists and hospital medicine practices as a toolkit for improving or ensuring job satisfaction. It outlines the four pillars of career satisfaction, the third of which is reward/recognition.

The Third Pillar

The reward/recognition pillar includes not just financial rewards but also social rewards (appreciation by your colleagues, leaders, patients, and family) and intrinsic rewards (healing patients or working efficiently and productively).

Achieving on-the-job recognition requires practicing high-quality medicine, communicating this to all the groups above, and participating in professional development and leadership. It also entails building relationships with peers and allied health professionals, hospital executives, patients, and the community.

“Reward and recognition ties in a lot with the other pillars—especially community,” says CSTF member Adrienne Bennett, MD, PhD, Ohio State University Medical Center, Columbus. “Part of what makes or breaks any hospitalist job is the group you work with and how you get along. This has to do with how you’re viewed and how you’re rewarded and supported.”

The classic dichotomy of values in hospital medicine is salary versus quality of life. Some groups offer higher salaries with heavy workloads and/or many shifts, and others value time over money. But there are additional values that affect reward and recognition. For example, let’s say you want to build a career or reputation in patient safety and quality of care but you work for a hospital medicine group focused mainly on high-volume patient care that is not engaged in quality improvement work. Your group may not value or reward your efforts. This can lead to job dissatisfaction.

“Make sure the group you join has a culture that shares or at least respects and supports your other career interests,” advises Dr. Bennett. “Working with a group where you’re a good fit and that supports your career aspirations is the most important aspect of career satisfaction.”

An Example of Reward Issues

To illustrate how reward/recognition works, here’s a fictional example of a hospitalist faced with a decision regarding her career:

“I’m ready to find my first job in hospital medicine, and my husband just accepted a pulmonary fellowship at a Midwestern university hospital. There are five hospital medicine groups in the area to choose from. I have to decide which I’d prefer to work for. My main priority is that I want to be ‘a name’ in hospital medicine—I want a chance to build a good reputation nationally.”

According to the white paper, a hospitalist in this position should take several steps to ensure career satisfaction:

Step 1: Assess your choices. Use the series of questions provided in the white paper to compare programs, including compensation and benefits.

“This hospitalist seems to want something more out of her work than just the rewards that come from taking excellent care of her patients,” observes Dr. Bennett. “When she’s interviewing, she needs to ask very carefully about opportunities for leadership development and for building her local reputation, which is the first step toward larger recognition. She needs to find out if the group supports and values work on hospital and/or medical association committees. Many community-based groups do support this.”

Step 2: Once you’re hired, set short- and long-term performance goals. Understand what you want to be recognized for, and outline what you want to accomplish—whether it’s a research project, a leadership role on a committee, or simply a standard of patient care you set for yourself.

Step 3: Participate in SHM chapter meetings. Network with physicians from other hospital medicine groups, get involved, and make a name for yourself.

How Your Rewards Stack up

Whether you’re questioning the compensation package at your long-term hospitalist position or weighing a decision on taking a new job, you’ll turn to available benchmark data on hospital medicine.

“There are a lot ways that benchmarks help and hurt,” warns Dr. Bennett. “Some of it isn’t very good because it’s based on very small numbers. If you’re dealing with an employer that relies on data [for compensation levels], it’s important to know what data they’re using. A reliable employer should share that information. Even the SHM benchmark data—which is probably the best we have, since it’s based on several thousand practicing hospitalists in a variety of settings—can’t always tell you how your job compares.”

Many variations within groups and individual jobs make it hard to compare positions side by side. Differentiating factors include salary and other compensation factors, patient load, shifts and schedule (including nights and weekends), and job responsibilities.

“Sometimes you can use the number of work [relative value units] RVUs to compare workloads,” Dr. Bennett suggests.

As with all the pillars of career satisfaction, the rewards and recognitions that come with your job must be measured against what other hospitalist positions offer—but more importantly against your values and priorities. TH

Jane Jerrard has written for The Hospitalist since 2005.

The federal government is moving toward offering monetary rewards for reporting on specific performance indicators. When hospitals begin to seek those rewards, hospitalists will be integrally involved.

The Centers for Medicare and Medicaid Services (CMS) has been tasked with developing an approach to value-based purchasing (VBP) for Medicare hospital services beginning in fiscal year 2009. Once the proposal is complete and approved by Congress, hospitals will receive differential payments tied to their performance.

VBP is similar to pay for performance (P4P) in that it links a bonus payment to reporting on performance of specific procedures. But the payment in this case is awarded to a hospital rather than a physician. The goals for the CMS proposal include:

• Improve clinical quality;
• Address underuse, overuse, and misuse of services;
• Encourage patient-centered care;
• Reduce adverse events and improve patient safety;
• Avoid unnecessary costs;
• Stimulate investments in structural components and the re-engineering of care processes;
• Make performance results transparent to and usable by consumers; and
• Avoid creating additional disparities in healthcare and work to reduce existing disparities.

CMS has hosted two listening sessions on the VBP program, during which healthcare providers were able to directly offer suggestions and opinions. The latest information, including an options paper based on the first listening session, is available online at www.cms.hhs.gov/center/hospital.asp.

“I was impressed with their responsiveness to the feedback they received at two listening sessions,” says Gregory B. Seymann, MD, associate clinical professor, University of California, San Diego School of Medicine, Division of Hospital Medicine, and a member of SHM’s Public Policy Committee. “I can see that the second options paper incorporates a lot of the comments from the first session.”

Aligning Measures

SHM has expressed support for CMS’ VBP proposal in a letter to the agency that also urged CMS to select candidate measures for hospitals that align with those for individual physicians under the Physician Quality Reporting Initiative (PQRI), which started July 1.

“These are very similar programs; one rewards hospitals for performing certain processes of care, and one rewards physicians for performing certain processes,” Dr. Seymann explains. “We’re simply asking CMS to make sure the measures [in VBP] match up with what physicians are asked to do. Many people voiced the same comment in the listening session.”

Although there are just 17 candidate measures proposed for the first year of the VBP program, the expectation is to add a considerable number as the program continues. Many candidate measures are similar or identical to those in the PQRI, such as giving aspirin on arrival and giving aspirin, beta-blockers, and ACE inhibitors on discharge for patients with acute myocardial infarction.

Additionally, the proposed measures are identical to those in the current P4P program most hospitals already participate in, known as Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU). The difference will be that instead of getting credit just for reporting the data as they do now, starting in 2009 hospitals must report publicly and perform at a certain level to get a payment update.

“Physicians, especially hospitalists, will need to watch this closely, as it is expected that the PQRI program, which is similar to RHQDAPU on the hospital level, will ultimately transition to a pay-for-performance program such as VBP,” says Dr. Seymann. “We can learn from the bumps in the road in the hospitals’ experience, and hopefully SHM can be active in ensuring that similar problems are anticipated prior to a physician-level pay-for-performance rollout. Furthermore, measures that will apply to hospitalists will likely mirror the hospital VBP measures.”

Rewards Program

Hospitals participating in the proposed VBP program can earn rewards based on two different criteria.

“This aspect is far and away the most important part of this program coming from CMS,” says Dr. Seymann. “They’ve learned from experience with the Premier [Hospital Quality Incentive Demonstration] project on hospital value-based purchasing that the hospitals that started out doing the best got the lion’s share of the reward because they were already doing well. Unfortunately, those that started at the bottom showed greater overall improvement but didn’t reach the top performance threshold, so they saw no financial recognition.”

So in the proposed VBP program, hospitals can demonstrate quality through overall performance on specific measures or through improvement over time in specific measures.

“Hospitals that reach the benchmark—the median of the top decile of performance—get the maximum number of points toward achieving the reward,” explains Dr. Seymann. “But hospitals can gain some points as long as they fall within the attainment range [between the 50th percentile and the mean of the top decile], proportional to how well they do. You get points for both the amount of improvement and the absolute attainment, and whichever score is higher comprises your score on that measure.”

Dr. Seymann calls this adjustment in the incentive structure “the most positive piece of this program,” explaining, “All hospitals have the opportunity to participate and to earn rewards.”

What It Means for Hospitalists

When VBP becomes a reality, how will that affect hospitalists?

“A lot of what hospitalists do for hospitals is improve quality,” says Dr. Seymann. “They’re likely to be asked to partner with their hospitals to put protocols in place for value-based purchasing. … Hospitals can’t make this work without physician participation, and a lot of hospital medicine groups are aligned with their hospitals on quality-improvement measures.”

It seems inevitable PQRI will morph into a CMS P4P or value-based purchasing program—or both. Whatever happens with these demonstration projects, hospitalists will be reporting on measures, and SHM wants to ensure those measures are appropriate.

“There are only 17 measures now; that’s a narrow sample to define quality at a hospital,” Dr. Seymann points out regarding VBP. “SHM will want to be involved in identifying gaps in care and recommending more measures in the future—like care coordination.” TH

Jane Jerrard also writes “Career Development” for The Hospitalist.

The federal government is moving toward offering monetary rewards for reporting on specific performance indicators. When hospitals begin to seek those rewards, hospitalists will be integrally involved.

The Centers for Medicare and Medicaid Services (CMS) has been tasked with developing an approach to value-based purchasing (VBP) for Medicare hospital services beginning in fiscal year 2009. Once the proposal is complete and approved by Congress, hospitals will receive differential payments tied to their performance.

VBP is similar to pay for performance (P4P) in that it links a bonus payment to reporting on performance of specific procedures. But the payment in this case is awarded to a hospital rather than a physician. The goals for the CMS proposal include:

• Improve clinical quality;
• Address underuse, overuse, and misuse of services;
• Encourage patient-centered care;
• Reduce adverse events and improve patient safety;
• Avoid unnecessary costs;
• Stimulate investments in structural components and the re-engineering of care processes;
• Make performance results transparent to and usable by consumers; and
• Avoid creating additional disparities in healthcare and work to reduce existing disparities.

CMS has hosted two listening sessions on the VBP program, during which healthcare providers were able to directly offer suggestions and opinions. The latest information, including an options paper based on the first listening session, is available online at www.cms.hhs.gov/center/hospital.asp.

“I was impressed with their responsiveness to the feedback they received at two listening sessions,” says Gregory B. Seymann, MD, associate clinical professor, University of California, San Diego School of Medicine, Division of Hospital Medicine, and a member of SHM’s Public Policy Committee. “I can see that the second options paper incorporates a lot of the comments from the first session.”

Aligning Measures

SHM has expressed support for CMS’ VBP proposal in a letter to the agency that also urged CMS to select candidate measures for hospitals that align with those for individual physicians under the Physician Quality Reporting Initiative (PQRI), which started July 1.

“These are very similar programs; one rewards hospitals for performing certain processes of care, and one rewards physicians for performing certain processes,” Dr. Seymann explains. “We’re simply asking CMS to make sure the measures [in VBP] match up with what physicians are asked to do. Many people voiced the same comment in the listening session.”

Although there are just 17 candidate measures proposed for the first year of the VBP program, the expectation is to add a considerable number as the program continues. Many candidate measures are similar or identical to those in the PQRI, such as giving aspirin on arrival and giving aspirin, beta-blockers, and ACE inhibitors on discharge for patients with acute myocardial infarction.

Additionally, the proposed measures are identical to those in the current P4P program most hospitals already participate in, known as Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU). The difference will be that instead of getting credit just for reporting the data as they do now, starting in 2009 hospitals must report publicly and perform at a certain level to get a payment update.

“Physicians, especially hospitalists, will need to watch this closely, as it is expected that the PQRI program, which is similar to RHQDAPU on the hospital level, will ultimately transition to a pay-for-performance program such as VBP,” says Dr. Seymann. “We can learn from the bumps in the road in the hospitals’ experience, and hopefully SHM can be active in ensuring that similar problems are anticipated prior to a physician-level pay-for-performance rollout. Furthermore, measures that will apply to hospitalists will likely mirror the hospital VBP measures.”

Rewards Program

Hospitals participating in the proposed VBP program can earn rewards based on two different criteria.

“This aspect is far and away the most important part of this program coming from CMS,” says Dr. Seymann. “They’ve learned from experience with the Premier [Hospital Quality Incentive Demonstration] project on hospital value-based purchasing that the hospitals that started out doing the best got the lion’s share of the reward because they were already doing well. Unfortunately, those that started at the bottom showed greater overall improvement but didn’t reach the top performance threshold, so they saw no financial recognition.”

So in the proposed VBP program, hospitals can demonstrate quality through overall performance on specific measures or through improvement over time in specific measures.

“Hospitals that reach the benchmark—the median of the top decile of performance—get the maximum number of points toward achieving the reward,” explains Dr. Seymann. “But hospitals can gain some points as long as they fall within the attainment range [between the 50th percentile and the mean of the top decile], proportional to how well they do. You get points for both the amount of improvement and the absolute attainment, and whichever score is higher comprises your score on that measure.”

Dr. Seymann calls this adjustment in the incentive structure “the most positive piece of this program,” explaining, “All hospitals have the opportunity to participate and to earn rewards.”

What It Means for Hospitalists

When VBP becomes a reality, how will that affect hospitalists?

“A lot of what hospitalists do for hospitals is improve quality,” says Dr. Seymann. “They’re likely to be asked to partner with their hospitals to put protocols in place for value-based purchasing. … Hospitals can’t make this work without physician participation, and a lot of hospital medicine groups are aligned with their hospitals on quality-improvement measures.”

It seems inevitable PQRI will morph into a CMS P4P or value-based purchasing program—or both. Whatever happens with these demonstration projects, hospitalists will be reporting on measures, and SHM wants to ensure those measures are appropriate.

“There are only 17 measures now; that’s a narrow sample to define quality at a hospital,” Dr. Seymann points out regarding VBP. “SHM will want to be involved in identifying gaps in care and recommending more measures in the future—like care coordination.” TH

Jane Jerrard also writes “Career Development” for The Hospitalist.

The federal government is moving toward offering monetary rewards for reporting on specific performance indicators. When hospitals begin to seek those rewards, hospitalists will be integrally involved.

The Centers for Medicare and Medicaid Services (CMS) has been tasked with developing an approach to value-based purchasing (VBP) for Medicare hospital services beginning in fiscal year 2009. Once the proposal is complete and approved by Congress, hospitals will receive differential payments tied to their performance.

VBP is similar to pay for performance (P4P) in that it links a bonus payment to reporting on performance of specific procedures. But the payment in this case is awarded to a hospital rather than a physician. The goals for the CMS proposal include:

• Improve clinical quality;
• Address underuse, overuse, and misuse of services;
• Encourage patient-centered care;
• Reduce adverse events and improve patient safety;
• Avoid unnecessary costs;
• Stimulate investments in structural components and the re-engineering of care processes;
• Make performance results transparent to and usable by consumers; and
• Avoid creating additional disparities in healthcare and work to reduce existing disparities.

CMS has hosted two listening sessions on the VBP program, during which healthcare providers were able to directly offer suggestions and opinions. The latest information, including an options paper based on the first listening session, is available online at www.cms.hhs.gov/center/hospital.asp.

“I was impressed with their responsiveness to the feedback they received at two listening sessions,” says Gregory B. Seymann, MD, associate clinical professor, University of California, San Diego School of Medicine, Division of Hospital Medicine, and a member of SHM’s Public Policy Committee. “I can see that the second options paper incorporates a lot of the comments from the first session.”

Aligning Measures

SHM has expressed support for CMS’ VBP proposal in a letter to the agency that also urged CMS to select candidate measures for hospitals that align with those for individual physicians under the Physician Quality Reporting Initiative (PQRI), which started July 1.

“These are very similar programs; one rewards hospitals for performing certain processes of care, and one rewards physicians for performing certain processes,” Dr. Seymann explains. “We’re simply asking CMS to make sure the measures [in VBP] match up with what physicians are asked to do. Many people voiced the same comment in the listening session.”

Although there are just 17 candidate measures proposed for the first year of the VBP program, the expectation is to add a considerable number as the program continues. Many candidate measures are similar or identical to those in the PQRI, such as giving aspirin on arrival and giving aspirin, beta-blockers, and ACE inhibitors on discharge for patients with acute myocardial infarction.

Additionally, the proposed measures are identical to those in the current P4P program most hospitals already participate in, known as Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU). The difference will be that instead of getting credit just for reporting the data as they do now, starting in 2009 hospitals must report publicly and perform at a certain level to get a payment update.

“Physicians, especially hospitalists, will need to watch this closely, as it is expected that the PQRI program, which is similar to RHQDAPU on the hospital level, will ultimately transition to a pay-for-performance program such as VBP,” says Dr. Seymann. “We can learn from the bumps in the road in the hospitals’ experience, and hopefully SHM can be active in ensuring that similar problems are anticipated prior to a physician-level pay-for-performance rollout. Furthermore, measures that will apply to hospitalists will likely mirror the hospital VBP measures.”

Rewards Program

Hospitals participating in the proposed VBP program can earn rewards based on two different criteria.

“This aspect is far and away the most important part of this program coming from CMS,” says Dr. Seymann. “They’ve learned from experience with the Premier [Hospital Quality Incentive Demonstration] project on hospital value-based purchasing that the hospitals that started out doing the best got the lion’s share of the reward because they were already doing well. Unfortunately, those that started at the bottom showed greater overall improvement but didn’t reach the top performance threshold, so they saw no financial recognition.”

So in the proposed VBP program, hospitals can demonstrate quality through overall performance on specific measures or through improvement over time in specific measures.

“Hospitals that reach the benchmark—the median of the top decile of performance—get the maximum number of points toward achieving the reward,” explains Dr. Seymann. “But hospitals can gain some points as long as they fall within the attainment range [between the 50th percentile and the mean of the top decile], proportional to how well they do. You get points for both the amount of improvement and the absolute attainment, and whichever score is higher comprises your score on that measure.”

Dr. Seymann calls this adjustment in the incentive structure “the most positive piece of this program,” explaining, “All hospitals have the opportunity to participate and to earn rewards.”

What It Means for Hospitalists

When VBP becomes a reality, how will that affect hospitalists?

“A lot of what hospitalists do for hospitals is improve quality,” says Dr. Seymann. “They’re likely to be asked to partner with their hospitals to put protocols in place for value-based purchasing. … Hospitals can’t make this work without physician participation, and a lot of hospital medicine groups are aligned with their hospitals on quality-improvement measures.”

It seems inevitable PQRI will morph into a CMS P4P or value-based purchasing program—or both. Whatever happens with these demonstration projects, hospitalists will be reporting on measures, and SHM wants to ensure those measures are appropriate.

“There are only 17 measures now; that’s a narrow sample to define quality at a hospital,” Dr. Seymann points out regarding VBP. “SHM will want to be involved in identifying gaps in care and recommending more measures in the future—like care coordination.” TH

Jane Jerrard also writes “Career Development” for The Hospitalist.

Many speakers at the recent SHM annual meeting in Dallas focused on the many ways hospitalists enhance quality of care. The teamwork necessary to effectively render inpatient services was an especially important topic.

Hospitalists have compiled a significant amount of descriptive material about their working environments and the composition and workloads of hospitalist teams. However, there is not much material available quantifying the ways that various disciplines impact the overall care-delivery metrics of multidisciplinary hospitalist teams.

The SHM Non-Physician Provider Committee is interested in collecting information on multidisciplinary programs, their component disciplines and individual providers to help identify and describe teams that have integrated nurse practitioners, physician assistants, clinical pharmacists and pharmacologists, nurse clinical care coordinators, and other related disciplines into their practices. Our goal is to develop descriptions of successful and unsuccessful implementation models.

click for large version

We would also like to collect information measuring additional domains of interest to major stakeholders. Such domains might include the clinical utilization of non-physician providers in relationship to both scope-of-practice and delegation of authority, the influence of multidisciplinary integration on patient-centered care and patient satisfaction, process and outcomes quality metrics, throughput and efficiency measures, documentation practices, hospital privileges for non-physicians, medical education in the multidisciplinary environment, risk management and, of course, reimbursement.

One might ask why the collection and analysis of such data should be of interest to hospitalists and to SHM. There are several immediate answers:

• The first reason involves manpower. Hospital medicine has become a growing discipline for physicians—one that did not exist on the radar screens of physician planners 10 years ago. However, given the growing demand for hospitalists there may be a significant shortage. To address this deficit, hospital medicine practices will need to attract new associates in the form of nurse practitioners and physician assistants. It is therefore imperative that hospitalists proactively identify barriers to the integration of non-physician providers into their practices and have successful implementation models to guide this effort.
• The second reason centers on the fact that hospitalists will continue to lead efforts to enhance quality of care. Incorporating a multidisciplinary approach—whether through the pre-rounding and follow-up of nurse clinical care coordinators, the counsel of clinical pharmacists, or the hands-on care of other disciplines—will facilitate throughput and improve quality as well as enhance patient satisfaction and communication. Identifying best practices in these particular domains will provide information crucial to success in these areas.
• The third reason is related to the cost of services. With declining reimbursements coupled with increasing costs, hospital medicine programs must identify and implement measures aimed at expense control and maximization of services. Used appropriately, non-physician providers provide a lower-cost alternative to a physician-only model. When one-to-one pairing occurs, physician/NPP team-care can be delivered in a parallel-versus-linear fashion, thus allowing for increased census as well as expedition of care.

The future of hospital medicine is one of continued growth with the demand for hospital medicine physicians far outstripping the available supply to meet the ever-increasing needs. SHM is committed to researching and sharing best practices, and views the use of multidisciplinary teams as an important model of care. Together, we can all achieve more.

If you are interested in being a part of this project or feel that this data would be of benefit to your practice, please contact the Non-Physician Provider Committee at nppcommittee@hospitalmedicine.org.

Chapter Reports

Nashville

Quite a bit of networking took place before the Medtronic-sponsored presentation at Ruth’s Chris in Nashville on April 26. The SHM Nashville Chapter has re-energized itself under the co-direction of Steven Embry, MD, and Kimberly Bell, MD. Eleven Nashville-area healthcare organizations were represented by more than 28 attendees. The attendees were a multidisciplinary mix of physicians, nurses, and administrators. Shashank Desai, MD, engaged the audience with his presentation “Simple to Complex: Advances in the Management of CHF.” Dr. Desai is the medical director of the Heart Failure and Transplant Program at Inova Fairfax Hospital.

Pacific Northwest

The latest Pacific Northwest Chapter meeting of SHM was held in Seattle on May 15. A change of venue and a new focus on speakers provided local hospitalists with information they won’t find elsewhere. Joseph Bennet, MD, former president of the local chapter, gave a presentation detailing his 15 months practicing hospitalist medicine in Dunedin, New Zealand. In addition to stunning photos of the terrain, Dr. Bennet delivered a thought-provoking presentation comparing New Zealand with the United States regarding culture, medical system financing, drug and care delivery, physician training, end-of-life issues, and many more aspects.

Pittsburgh

The Pittsburgh Chapter had a meeting May 10 at Morton’s Steakhouse. The speaker for the event was Rene Alvarez, MD, director of the Critical Care Unit at University of Pittsburgh Medical Center. Dr. Alvarez discussed “Strategies for Optimal Management of Patients with Heart Failure,” which generated an excellent discussion. Various hospital medicine topics including incentives, program structures, and 24/7 programs were also discussed. Attendees included hospitalists from six local hospitals. The next meeting will be held Oct. 30. For more information on the Pittsburgh Chapter, contact Michael Cratty, MD, PhD, at mcratty@wpahs.org.

Rocky Mountain

The Rocky Mountain Chapter held its spring meeting May 3 at the Denver Colorado Downtown Aquarium. Chapter President Eugene Chu, MD, welcomed attendees and was followed by an update from the Rocky Mountain Chapter Public Policy Committee presented by Bob Brockmann, MD, MSc. Guest speakers for the night were Edward Maa, MD, who spoke about “Seizure Management in Hospitalized Patients” and Daniel Mogyoros, MD, whose presentation was titled “Updates in Infectious Disease for Hospital Medicine.” Attendees received two AMA PRA [Physician’s Recognition Award] Category 1 credits.

San Diego

At its June 5 meeting, San Diego’s chapter discussed real-time, evidence-based practice as a means to improve patient care and share new clinical evidence with colleagues. Online access during the presentation allowed the group to review several evidence resources: PubMed, the Physician’s Information and Education Resource, the American College of Physicians Journal Club, and National Guideline Clearing House using real patient cases. Dinner was served by Blue Coral Seafood and Spirits, and Novartis sponsored the event.

Upstate South Carolina

The second meeting of the Upstate S.C. Chapter was held May 15, with close to 20 physicians representing five hospitals in upstate South Carolina. Kenneth Leeper, MD, pulmonologist, presented information on ventilator-associated pneumonia. Following the presentation, the business meeting was opened by outgoing President Raja Paladugu, MD.

The following officers were elected for 2007:

• President: Zafar Hossain, MD;
• Vice President: Imran Shaikh, MD; and
• Secretary: Shawn Morrow, MD.

The group decided to meet on a quarterly basis, with the next meeting to be held in September. TH

Many speakers at the recent SHM annual meeting in Dallas focused on the many ways hospitalists enhance quality of care. The teamwork necessary to effectively render inpatient services was an especially important topic.

Hospitalists have compiled a significant amount of descriptive material about their working environments and the composition and workloads of hospitalist teams. However, there is not much material available quantifying the ways that various disciplines impact the overall care-delivery metrics of multidisciplinary hospitalist teams.

The SHM Non-Physician Provider Committee is interested in collecting information on multidisciplinary programs, their component disciplines and individual providers to help identify and describe teams that have integrated nurse practitioners, physician assistants, clinical pharmacists and pharmacologists, nurse clinical care coordinators, and other related disciplines into their practices. Our goal is to develop descriptions of successful and unsuccessful implementation models.

click for large version

We would also like to collect information measuring additional domains of interest to major stakeholders. Such domains might include the clinical utilization of non-physician providers in relationship to both scope-of-practice and delegation of authority, the influence of multidisciplinary integration on patient-centered care and patient satisfaction, process and outcomes quality metrics, throughput and efficiency measures, documentation practices, hospital privileges for non-physicians, medical education in the multidisciplinary environment, risk management and, of course, reimbursement.

One might ask why the collection and analysis of such data should be of interest to hospitalists and to SHM. There are several immediate answers:

• The first reason involves manpower. Hospital medicine has become a growing discipline for physicians—one that did not exist on the radar screens of physician planners 10 years ago. However, given the growing demand for hospitalists there may be a significant shortage. To address this deficit, hospital medicine practices will need to attract new associates in the form of nurse practitioners and physician assistants. It is therefore imperative that hospitalists proactively identify barriers to the integration of non-physician providers into their practices and have successful implementation models to guide this effort.
• The second reason centers on the fact that hospitalists will continue to lead efforts to enhance quality of care. Incorporating a multidisciplinary approach—whether through the pre-rounding and follow-up of nurse clinical care coordinators, the counsel of clinical pharmacists, or the hands-on care of other disciplines—will facilitate throughput and improve quality as well as enhance patient satisfaction and communication. Identifying best practices in these particular domains will provide information crucial to success in these areas.
• The third reason is related to the cost of services. With declining reimbursements coupled with increasing costs, hospital medicine programs must identify and implement measures aimed at expense control and maximization of services. Used appropriately, non-physician providers provide a lower-cost alternative to a physician-only model. When one-to-one pairing occurs, physician/NPP team-care can be delivered in a parallel-versus-linear fashion, thus allowing for increased census as well as expedition of care.

The future of hospital medicine is one of continued growth with the demand for hospital medicine physicians far outstripping the available supply to meet the ever-increasing needs. SHM is committed to researching and sharing best practices, and views the use of multidisciplinary teams as an important model of care. Together, we can all achieve more.

If you are interested in being a part of this project or feel that this data would be of benefit to your practice, please contact the Non-Physician Provider Committee at nppcommittee@hospitalmedicine.org.

Chapter Reports

Nashville

Quite a bit of networking took place before the Medtronic-sponsored presentation at Ruth’s Chris in Nashville on April 26. The SHM Nashville Chapter has re-energized itself under the co-direction of Steven Embry, MD, and Kimberly Bell, MD. Eleven Nashville-area healthcare organizations were represented by more than 28 attendees. The attendees were a multidisciplinary mix of physicians, nurses, and administrators. Shashank Desai, MD, engaged the audience with his presentation “Simple to Complex: Advances in the Management of CHF.” Dr. Desai is the medical director of the Heart Failure and Transplant Program at Inova Fairfax Hospital.

Pacific Northwest

The latest Pacific Northwest Chapter meeting of SHM was held in Seattle on May 15. A change of venue and a new focus on speakers provided local hospitalists with information they won’t find elsewhere. Joseph Bennet, MD, former president of the local chapter, gave a presentation detailing his 15 months practicing hospitalist medicine in Dunedin, New Zealand. In addition to stunning photos of the terrain, Dr. Bennet delivered a thought-provoking presentation comparing New Zealand with the United States regarding culture, medical system financing, drug and care delivery, physician training, end-of-life issues, and many more aspects.

Pittsburgh

The Pittsburgh Chapter had a meeting May 10 at Morton’s Steakhouse. The speaker for the event was Rene Alvarez, MD, director of the Critical Care Unit at University of Pittsburgh Medical Center. Dr. Alvarez discussed “Strategies for Optimal Management of Patients with Heart Failure,” which generated an excellent discussion. Various hospital medicine topics including incentives, program structures, and 24/7 programs were also discussed. Attendees included hospitalists from six local hospitals. The next meeting will be held Oct. 30. For more information on the Pittsburgh Chapter, contact Michael Cratty, MD, PhD, at mcratty@wpahs.org.

Rocky Mountain

The Rocky Mountain Chapter held its spring meeting May 3 at the Denver Colorado Downtown Aquarium. Chapter President Eugene Chu, MD, welcomed attendees and was followed by an update from the Rocky Mountain Chapter Public Policy Committee presented by Bob Brockmann, MD, MSc. Guest speakers for the night were Edward Maa, MD, who spoke about “Seizure Management in Hospitalized Patients” and Daniel Mogyoros, MD, whose presentation was titled “Updates in Infectious Disease for Hospital Medicine.” Attendees received two AMA PRA [Physician’s Recognition Award] Category 1 credits.

San Diego

At its June 5 meeting, San Diego’s chapter discussed real-time, evidence-based practice as a means to improve patient care and share new clinical evidence with colleagues. Online access during the presentation allowed the group to review several evidence resources: PubMed, the Physician’s Information and Education Resource, the American College of Physicians Journal Club, and National Guideline Clearing House using real patient cases. Dinner was served by Blue Coral Seafood and Spirits, and Novartis sponsored the event.

Upstate South Carolina

The second meeting of the Upstate S.C. Chapter was held May 15, with close to 20 physicians representing five hospitals in upstate South Carolina. Kenneth Leeper, MD, pulmonologist, presented information on ventilator-associated pneumonia. Following the presentation, the business meeting was opened by outgoing President Raja Paladugu, MD.

The following officers were elected for 2007:

• President: Zafar Hossain, MD;
• Vice President: Imran Shaikh, MD; and
• Secretary: Shawn Morrow, MD.

The group decided to meet on a quarterly basis, with the next meeting to be held in September. TH

Many speakers at the recent SHM annual meeting in Dallas focused on the many ways hospitalists enhance quality of care. The teamwork necessary to effectively render inpatient services was an especially important topic.

Hospitalists have compiled a significant amount of descriptive material about their working environments and the composition and workloads of hospitalist teams. However, there is not much material available quantifying the ways that various disciplines impact the overall care-delivery metrics of multidisciplinary hospitalist teams.

The SHM Non-Physician Provider Committee is interested in collecting information on multidisciplinary programs, their component disciplines and individual providers to help identify and describe teams that have integrated nurse practitioners, physician assistants, clinical pharmacists and pharmacologists, nurse clinical care coordinators, and other related disciplines into their practices. Our goal is to develop descriptions of successful and unsuccessful implementation models.

click for large version

We would also like to collect information measuring additional domains of interest to major stakeholders. Such domains might include the clinical utilization of non-physician providers in relationship to both scope-of-practice and delegation of authority, the influence of multidisciplinary integration on patient-centered care and patient satisfaction, process and outcomes quality metrics, throughput and efficiency measures, documentation practices, hospital privileges for non-physicians, medical education in the multidisciplinary environment, risk management and, of course, reimbursement.

One might ask why the collection and analysis of such data should be of interest to hospitalists and to SHM. There are several immediate answers:

• The first reason involves manpower. Hospital medicine has become a growing discipline for physicians—one that did not exist on the radar screens of physician planners 10 years ago. However, given the growing demand for hospitalists there may be a significant shortage. To address this deficit, hospital medicine practices will need to attract new associates in the form of nurse practitioners and physician assistants. It is therefore imperative that hospitalists proactively identify barriers to the integration of non-physician providers into their practices and have successful implementation models to guide this effort.
• The second reason centers on the fact that hospitalists will continue to lead efforts to enhance quality of care. Incorporating a multidisciplinary approach—whether through the pre-rounding and follow-up of nurse clinical care coordinators, the counsel of clinical pharmacists, or the hands-on care of other disciplines—will facilitate throughput and improve quality as well as enhance patient satisfaction and communication. Identifying best practices in these particular domains will provide information crucial to success in these areas.
• The third reason is related to the cost of services. With declining reimbursements coupled with increasing costs, hospital medicine programs must identify and implement measures aimed at expense control and maximization of services. Used appropriately, non-physician providers provide a lower-cost alternative to a physician-only model. When one-to-one pairing occurs, physician/NPP team-care can be delivered in a parallel-versus-linear fashion, thus allowing for increased census as well as expedition of care.

The future of hospital medicine is one of continued growth with the demand for hospital medicine physicians far outstripping the available supply to meet the ever-increasing needs. SHM is committed to researching and sharing best practices, and views the use of multidisciplinary teams as an important model of care. Together, we can all achieve more.

If you are interested in being a part of this project or feel that this data would be of benefit to your practice, please contact the Non-Physician Provider Committee at nppcommittee@hospitalmedicine.org.

Chapter Reports

Nashville

Quite a bit of networking took place before the Medtronic-sponsored presentation at Ruth’s Chris in Nashville on April 26. The SHM Nashville Chapter has re-energized itself under the co-direction of Steven Embry, MD, and Kimberly Bell, MD. Eleven Nashville-area healthcare organizations were represented by more than 28 attendees. The attendees were a multidisciplinary mix of physicians, nurses, and administrators. Shashank Desai, MD, engaged the audience with his presentation “Simple to Complex: Advances in the Management of CHF.” Dr. Desai is the medical director of the Heart Failure and Transplant Program at Inova Fairfax Hospital.

Pacific Northwest

The latest Pacific Northwest Chapter meeting of SHM was held in Seattle on May 15. A change of venue and a new focus on speakers provided local hospitalists with information they won’t find elsewhere. Joseph Bennet, MD, former president of the local chapter, gave a presentation detailing his 15 months practicing hospitalist medicine in Dunedin, New Zealand. In addition to stunning photos of the terrain, Dr. Bennet delivered a thought-provoking presentation comparing New Zealand with the United States regarding culture, medical system financing, drug and care delivery, physician training, end-of-life issues, and many more aspects.

Pittsburgh

The Pittsburgh Chapter had a meeting May 10 at Morton’s Steakhouse. The speaker for the event was Rene Alvarez, MD, director of the Critical Care Unit at University of Pittsburgh Medical Center. Dr. Alvarez discussed “Strategies for Optimal Management of Patients with Heart Failure,” which generated an excellent discussion. Various hospital medicine topics including incentives, program structures, and 24/7 programs were also discussed. Attendees included hospitalists from six local hospitals. The next meeting will be held Oct. 30. For more information on the Pittsburgh Chapter, contact Michael Cratty, MD, PhD, at mcratty@wpahs.org.

Rocky Mountain

The Rocky Mountain Chapter held its spring meeting May 3 at the Denver Colorado Downtown Aquarium. Chapter President Eugene Chu, MD, welcomed attendees and was followed by an update from the Rocky Mountain Chapter Public Policy Committee presented by Bob Brockmann, MD, MSc. Guest speakers for the night were Edward Maa, MD, who spoke about “Seizure Management in Hospitalized Patients” and Daniel Mogyoros, MD, whose presentation was titled “Updates in Infectious Disease for Hospital Medicine.” Attendees received two AMA PRA [Physician’s Recognition Award] Category 1 credits.

San Diego

At its June 5 meeting, San Diego’s chapter discussed real-time, evidence-based practice as a means to improve patient care and share new clinical evidence with colleagues. Online access during the presentation allowed the group to review several evidence resources: PubMed, the Physician’s Information and Education Resource, the American College of Physicians Journal Club, and National Guideline Clearing House using real patient cases. Dinner was served by Blue Coral Seafood and Spirits, and Novartis sponsored the event.

Upstate South Carolina

The second meeting of the Upstate S.C. Chapter was held May 15, with close to 20 physicians representing five hospitals in upstate South Carolina. Kenneth Leeper, MD, pulmonologist, presented information on ventilator-associated pneumonia. Following the presentation, the business meeting was opened by outgoing President Raja Paladugu, MD.

The following officers were elected for 2007:

• President: Zafar Hossain, MD;
• Vice President: Imran Shaikh, MD; and
• Secretary: Shawn Morrow, MD.

The group decided to meet on a quarterly basis, with the next meeting to be held in September. TH

Jane Jerrard covered some potential career paths for academic hospitalists in her article “How to Navigate Hospital Medicine” (May 2007, p. 9). But I believe her account was incomplete. I would like to add detail to the opportunities in community-based and other programs.

Community-based medical groups offer a number of opportunities in hospitals or hospital systems. These include:

• Committee chairman. Most hospitals want interested, dedicated individuals to chair traditional medical staff committees. Hospitalists are well suited because our unique perspective lets us identify processes or products that can help many patients. Begin by serving on a committee, such as ethics, pharmacy and therapeutics, IRB, or departmental peer review. As you get comfortable, discuss potential chairmanships with the chief of staff or the vice president of medical affairs (VPMA). Don’t expect to advance if you don’t show up or don’t come prepared to committee meetings.
• Department chairperson. These positions are often elected and may allow one to serve on the credentials committee and the medical executive committee.
• Medical staff officers. Hospitalists often are elected to these key positions and gain access to administration and various committees.
• Project manager. Installing and using electronic medical records and devices calls for physician involvement in design and support. These are great chances to work on interesting projects and affect the tools you work with.
• Hospital administrative positions. Many hospitals have a VPMA or a chief medical officer (CMO), and some are developing the role of vice president of quality. These can be full- or part-time positions. You will be expected to help members of the medical staff implement change, and you should have experience and proven effectiveness in prior roles. Several predict that hospital COOs and CEOs of the future will be hospitalists.

Another path of opportunity is within your organization, depending on your employer. These roles may overlap with hospital positions:

• Group leader. Generally responsible for working on scheduling, recruitment, and organizational structure. The job may involve responsibility for one or more facilities.
• Compliance officer. Someone in the group must understand billing, coding, and proper use of rules and legislation.
• Quality and safety officer.
• Group president.

Hospitalists can also participate on committees that deal with such areas as pension plans, contracts, or other business.

Health insurance companies provide opportunities for individuals to practice part-time and serve as medical directors. They also have career paths for VPMAs and CMOs.

Also, many healthcare companies have been started and run by physicians. Invent something; start a company. The opportunities are endless.

Some other tips:

• Educate yourself. Take courses like the SHM Leadership Academy. Learn how to interact in a businesslike manner. Some on-the-job training is OK, but management and leadership are new fields that require new learning.
• Read. There are many great books on being an executive. Learn how to run a meeting, make an agenda, work with other professionals, and delegate.
• Ask for help. Find an individual or individuals with whom you can discuss ideas. Some of your best mentors will be managers in other fields.

Mary Jo Gorman, MD, MBA

Immediate Past President, SHM

Consequences of Locum Tenens Work

I feel one piece of advice in the Career Development section in the May issue of The Hospitalist (“How to Navigate Hospital Medicine,” p. 9) is not complete and may adversely affect a new hospitalist’s career.

The article recommends exploring locum tenens work. We have found two unintended consequences of such action. First, the locum companies usually have a buyout clause for the physician. Should he decide he likes a location and wishes to stay, the potential employer faces an additional cost in the $20,000-$30,000 range. It makes budgeting difficult. Also, there is usually a clause in the locum contract that this policy is in place for two years after leaving the locum company.

Second, frequent job changes lead to prolonged processing of credentials at hospitals as they verify good standing at all previous practice sites. This means delays that force a hospitalist company to look for more readily available docs. The physician may be unable to find hospitals in highly desirable areas.

The article was otherwise well balanced and timely.

George Block, MD

CMO, Galen Inpatient Physicians Medical Group

Emeryville, Calif.

Jane Jerrard covered some potential career paths for academic hospitalists in her article “How to Navigate Hospital Medicine” (May 2007, p. 9). But I believe her account was incomplete. I would like to add detail to the opportunities in community-based and other programs.

Community-based medical groups offer a number of opportunities in hospitals or hospital systems. These include:

• Committee chairman. Most hospitals want interested, dedicated individuals to chair traditional medical staff committees. Hospitalists are well suited because our unique perspective lets us identify processes or products that can help many patients. Begin by serving on a committee, such as ethics, pharmacy and therapeutics, IRB, or departmental peer review. As you get comfortable, discuss potential chairmanships with the chief of staff or the vice president of medical affairs (VPMA). Don’t expect to advance if you don’t show up or don’t come prepared to committee meetings.
• Department chairperson. These positions are often elected and may allow one to serve on the credentials committee and the medical executive committee.
• Medical staff officers. Hospitalists often are elected to these key positions and gain access to administration and various committees.
• Project manager. Installing and using electronic medical records and devices calls for physician involvement in design and support. These are great chances to work on interesting projects and affect the tools you work with.
• Hospital administrative positions. Many hospitals have a VPMA or a chief medical officer (CMO), and some are developing the role of vice president of quality. These can be full- or part-time positions. You will be expected to help members of the medical staff implement change, and you should have experience and proven effectiveness in prior roles. Several predict that hospital COOs and CEOs of the future will be hospitalists.

Another path of opportunity is within your organization, depending on your employer. These roles may overlap with hospital positions:

• Group leader. Generally responsible for working on scheduling, recruitment, and organizational structure. The job may involve responsibility for one or more facilities.
• Compliance officer. Someone in the group must understand billing, coding, and proper use of rules and legislation.
• Quality and safety officer.
• Group president.

Hospitalists can also participate on committees that deal with such areas as pension plans, contracts, or other business.

Health insurance companies provide opportunities for individuals to practice part-time and serve as medical directors. They also have career paths for VPMAs and CMOs.

Also, many healthcare companies have been started and run by physicians. Invent something; start a company. The opportunities are endless.

Some other tips:

• Educate yourself. Take courses like the SHM Leadership Academy. Learn how to interact in a businesslike manner. Some on-the-job training is OK, but management and leadership are new fields that require new learning.
• Read. There are many great books on being an executive. Learn how to run a meeting, make an agenda, work with other professionals, and delegate.
• Ask for help. Find an individual or individuals with whom you can discuss ideas. Some of your best mentors will be managers in other fields.

Mary Jo Gorman, MD, MBA

Immediate Past President, SHM

Consequences of Locum Tenens Work

I feel one piece of advice in the Career Development section in the May issue of The Hospitalist (“How to Navigate Hospital Medicine,” p. 9) is not complete and may adversely affect a new hospitalist’s career.

The article recommends exploring locum tenens work. We have found two unintended consequences of such action. First, the locum companies usually have a buyout clause for the physician. Should he decide he likes a location and wishes to stay, the potential employer faces an additional cost in the $20,000-$30,000 range. It makes budgeting difficult. Also, there is usually a clause in the locum contract that this policy is in place for two years after leaving the locum company.

Second, frequent job changes lead to prolonged processing of credentials at hospitals as they verify good standing at all previous practice sites. This means delays that force a hospitalist company to look for more readily available docs. The physician may be unable to find hospitals in highly desirable areas.

The article was otherwise well balanced and timely.

George Block, MD

CMO, Galen Inpatient Physicians Medical Group

Emeryville, Calif.

Jane Jerrard covered some potential career paths for academic hospitalists in her article “How to Navigate Hospital Medicine” (May 2007, p. 9). But I believe her account was incomplete. I would like to add detail to the opportunities in community-based and other programs.

Community-based medical groups offer a number of opportunities in hospitals or hospital systems. These include:

• Committee chairman. Most hospitals want interested, dedicated individuals to chair traditional medical staff committees. Hospitalists are well suited because our unique perspective lets us identify processes or products that can help many patients. Begin by serving on a committee, such as ethics, pharmacy and therapeutics, IRB, or departmental peer review. As you get comfortable, discuss potential chairmanships with the chief of staff or the vice president of medical affairs (VPMA). Don’t expect to advance if you don’t show up or don’t come prepared to committee meetings.
• Department chairperson. These positions are often elected and may allow one to serve on the credentials committee and the medical executive committee.
• Medical staff officers. Hospitalists often are elected to these key positions and gain access to administration and various committees.
• Project manager. Installing and using electronic medical records and devices calls for physician involvement in design and support. These are great chances to work on interesting projects and affect the tools you work with.
• Hospital administrative positions. Many hospitals have a VPMA or a chief medical officer (CMO), and some are developing the role of vice president of quality. These can be full- or part-time positions. You will be expected to help members of the medical staff implement change, and you should have experience and proven effectiveness in prior roles. Several predict that hospital COOs and CEOs of the future will be hospitalists.

Another path of opportunity is within your organization, depending on your employer. These roles may overlap with hospital positions:

• Group leader. Generally responsible for working on scheduling, recruitment, and organizational structure. The job may involve responsibility for one or more facilities.
• Compliance officer. Someone in the group must understand billing, coding, and proper use of rules and legislation.
• Quality and safety officer.
• Group president.

Hospitalists can also participate on committees that deal with such areas as pension plans, contracts, or other business.

Health insurance companies provide opportunities for individuals to practice part-time and serve as medical directors. They also have career paths for VPMAs and CMOs.

Also, many healthcare companies have been started and run by physicians. Invent something; start a company. The opportunities are endless.

Some other tips:

• Educate yourself. Take courses like the SHM Leadership Academy. Learn how to interact in a businesslike manner. Some on-the-job training is OK, but management and leadership are new fields that require new learning.
• Read. There are many great books on being an executive. Learn how to run a meeting, make an agenda, work with other professionals, and delegate.
• Ask for help. Find an individual or individuals with whom you can discuss ideas. Some of your best mentors will be managers in other fields.

Mary Jo Gorman, MD, MBA

Immediate Past President, SHM

Consequences of Locum Tenens Work

I feel one piece of advice in the Career Development section in the May issue of The Hospitalist (“How to Navigate Hospital Medicine,” p. 9) is not complete and may adversely affect a new hospitalist’s career.

The article recommends exploring locum tenens work. We have found two unintended consequences of such action. First, the locum companies usually have a buyout clause for the physician. Should he decide he likes a location and wishes to stay, the potential employer faces an additional cost in the $20,000-$30,000 range. It makes budgeting difficult. Also, there is usually a clause in the locum contract that this policy is in place for two years after leaving the locum company.

Second, frequent job changes lead to prolonged processing of credentials at hospitals as they verify good standing at all previous practice sites. This means delays that force a hospitalist company to look for more readily available docs. The physician may be unable to find hospitals in highly desirable areas.

The article was otherwise well balanced and timely.

George Block, MD

CMO, Galen Inpatient Physicians Medical Group

Emeryville, Calif.

On March 16, the John A. Hartford Foundation awarded SHM a $1.4 million grant to develop interventions to improve care transitions for older adults at the time of hospital discharge.

One of the core values of SHM and hospital medicine is to implement changes that improve the care older Americans receive. With this grant support from The Hartford Foundation, SHM can help define and set standards for best practices in discharge and provide a continuum of training opportunities to support those practices.

As part of this three-year project, SHM will partner with national leaders in care coordination to form a national advisory board, create clinical tools, implement guidelines, and provide technical support and training tools to hospitals across the U.S. The project aims to build capacity in at least 200 hospital sites to improve the discharge process and, ultimately, health outcomes for older adults.

Chapter Report

Los Angeles: The kick-off meeting for the Los Angeles chapter was held at Spago Beverly Hills on April 10. The meeting brought together approximately 25 physicians from eight hospitalist groups throughout Los Angeles County. Larry Wellikson, MD, CEO of SHM, gave a presentation, “The Emergence and Future of Hospital Medicine.” Dr. Wellikson illuminated many important points in his talk and encouraged attendees to become involved in quality improvement at their own hospitals. The meeting was supported by Ortho Biotech.

National Advisory Board AND Project Team

SHM has assembled a national advisory board to inform and guide the project. The board will be chaired by Eric Coleman, MD, MPH, associate professor of medicine within the divisions of healthcare policy and research and geriatric medicine at the University of Colorado Health Sciences Center in Aurora. At press time, members included:

• Barbara Berkman, DSW, PhD, professor of health and mental health, University School of Social Work, Mount Sinai School of Medicine;
• Tom Bookwalter, PharmD, clinical pharmacist, American Society of Health-System Pharmacists (ASHP);
• Alan Korn, MD, chief medical officer and senior vice president for clinical affairs, Blue Cross Blue Shield Association;
• Chuck Denham, MD, chair, National Quality Forum (NQF);
• Gavin Hougham, PhD, senior program officer, John A. Hartford Foundation;
• Seth Landefeld, MD, director, American Geriatrics Society (AGS);
• Cheri Lattimer, RN, BSN, executive director, Case Management Society of America (CMSA);
• William Lyons, MD, AGS; Nebraska Medical Center in Omaha;
• Lorraine Mion, PhD, RN, FAAN, director of nursing services for geriatrics, Metro Health Medical Center in Cleveland, Ohio;
• Mary Naylor, PhD, RN, FAANS, Marian S. Ware professor in gerontology, University of Pennsylvania;
• Gail Povar, MD, MPH, chair, George Washington School of Medicine, Cameron Medical Group;
• Deborah Queenan, national advisory council coordinator, Agency for Healthcare Research and Quality (AHRQ);
• Pat Rutherford, RN, MS, vice president, Institute for Healthcare Improvement (IHI), Transforming Care at the Bedside (TCAB);
• Eric Warm, MD, Society General Internal Medicine (SGIM); and
• Larry Wellikson, MD, CEO of SHM.

Dr. Williams will serve as principal investigator, leading a team of co-investigators including Jeffrey Greenwald, MD, (Boston University co-investigator, AHRQ, Project ReEngineering Discharge); Eric Howell, MD (Johns Hopkins Bayview, SHM/Hartford Safe Steps Demonstration Project); Param Dedhia, MD (Johns Hopkins Bayview, SHM/Hartford Safe STEPS Demonstration Project); Lakshmi Halasyamani, MD (St. Joseph Mercy Hospital); Kathleen Kerr (SHM); and Tina Budnitz, MPH (SHM).

The project team includes investigators from the SHM/Hartford Foundation Safe STEPS project and two AHRQ-funded projects. All three projects aim to pilot test discharge-planning toolkits and interventions and develop implementation strategies for adoption. The current project will leverage the findings of all three projects with the insights of the advisory board to create a transitions bundle to optimize the discharge process. Following development of this bundle, SHM will develop a toolkit for implementation with corresponding training programs, and other technical support.

click for large version

Capacity Building Via Continuum of Training Options

SHM has designed a range of technical support and training options to meet the needs of member institutions aiming to implement and sustain the transitions bundle. Strategies include:

• A Web-based resource room for care transitions in older adults: The transitions bundle, field guide, and related interventional materials will be freely available in the SHM online resource room.
• A Quality Pre-Course for QI Teams: The course is scheduled for 2008 and 2009 SHM Annual Meetings.
• A Transition Planning Mentored Implementation Program (TPMI): This yearlong mentoring program will support sites as they implement and evaluate transitions bundle interventions. The program includes a training conference, monthly teleconferences with expert mentors and peer support mechanisms.
• A consultation service: This will provide on-site consultation and technical assistance to sites planning, implementing, and evaluating discharge interventions. The service includes site visit, follow-up report of findings, recommendations and resources, and post-visit follow-up to review progress, successes and unforeseen barriers.

These support mechanisms are intended to assist those who lead improvement teams at their institutions. Enrollment will begin in the fall. For more information, contact tbudnitz@hospitalmedicine.org.

A Seat at the Table

SHM active in shaping new performance standards

By Jane Jerrard

Healthcare providers are in the midst of important changes in how they work and how they’re rewarded for that work. Recent initiatives including Medicare’s Physician Quality Reporting Initiative and a Medicare hospital value-based purchasing program mandated by the Deficit Reduction Act spell change for practitioners, including hospitalists.

SHM is working to add a hospitalist voice to discussions and decisions that shape these initiatives. By participating in organizations such as the American Medical Association’s (AMA) Physician consortium for Performance Improvement (PCPI), SHM has a seat at the table where decisions are made.

How Participation Works

The PCPI was convened in 2001 by the AMA, with the mission of physician-led performance improvement. While the primary focus is on improving quality, the Consortium’s performance measures are ultimately those used in CMS and other pay-for-performance (P4P) programs and value-based purchasing initiatives.

SHM didn’t get involved when the PCPI was first formed because the issues weren’t relevant to hospitalists. “SHM was invited to participate at that time, but the focus was really on outpatient care,” says Patrick J. Torcson, MD, MMM, FACP, director of hospital medicine at St. Tammany Parish Hospital in Covington, La. “More recently, when the PCPI began looking at the relation between hospital-level measures and physician-level measures, SHM CEO Larry Wellikson said we need to get involved.”

Dr. Torcson is SHM’s representative on the consortium. “For the last year and a half, I’ve been attending the PCPI meetings to represent SHM and have been involved in various PCPI work groups,” he says. “I had previously served on the SHM HQPS [Healthcare Quality and Patient Safety Task Force] and now serve on the PPC [Public Policy Committee], and I think the SHM leadership thought that combination of interests would be good for a PCPI representative.”

What about the Work Groups?

Work groups within the PCPI are assigned specific areas. These groups are responsible for creating performance measures within an area, which are then reviewed by the entire consortium.

“I participated on a work group to develop performance measures for emergency medicine physicians,” says Dr. Torcson. “This group thought that the current disease-specific measures weren’t relevant for them, and that the current hospital measures were also not relevant. I provided a hospitalist’s perspective on hand-offs and discharge which was really focused on a process of care that begins in the ED [emergency department].”

Each work group has representation from various areas of healthcare. “My work group had about 20 or 25 people, which is probably typical,” says Dr. Torcson. “The AMA provided a methodologist, and there was a CMS representative on the work group.” The work group first met face to face to review relevant evidence-based clinical guidelines and scame up with five to eight measures. These were then reworked through phone calls and e-mails before going before the entire PCPI for approval.

Other SHM representatives participated in relevant PCPI work groups as well. “PPC member Greg Seymann from San Diego participated in a geriatric work group that was convened for the same reason” as the ED group, says Dr. Torcson. “His group looked at creating a number of measures that were relative to both inpatient and outpatient geriatric patients. Some of these measures are now part of the Medicare Physician Quality Reporting Initiative.”

Another SHM member, James C. Pile. MD, FACP, participated in a work group on developing measures for outpatient administration of IV antibiotics. Pile is a staff physician in the Department of General Internal Medicine, Section of Hospital Medicine, at The Cleveland Clinic in Ohio.

In each group, SHM representatives were able to help shape measures that reflect the unique knowledge and perspective of hospital medicine.

“A hospitalist brings the perspective of having seen how these measures are actually incorporated into a practice, how they are actually applied to patient care,” Dr. Torcson points out. “These work groups to develop additional performance measures are ongoing. The PCPI has a rigorous agenda for what they want to accomplish over the next few years.”

SHM to Lead the Way on Care Transitions

The PCPI has asked SHM to be the lead organization for a performance measure development work group on care coordination and care transitions.

“This will be groundbreaking work around this important aspect of care that is very process-focused as opposed to disease-focused,” says Dr. Torcson. “It’s very appropriate that SHM was asked to be the lead group for this. This area of performance improvement is perfect for what hospitalists do.”

The PCPI plans to have care transition performance measures ready for adoption by 2009.

SHM and the Big Three

CMS is also collaborating with the National Quality Forum (NQF) and Ambulatory Quality Alliance (AQA). “The PCPI, AQA, and NQF are the most influential organizations right now for quality and performance measures,” says Dr. Torcson.

The NQF, a unique public and private collaborative, develops consensus standards on different measures submitted to it. “I have had the opportunity to participate on an NQF Steering Committee for performance measure endorsement,” says Dr. Torcson.

The AQA is responsible for standardizing performance measurement and reporting, and developing measures for efficiency to be included in forthcoming Medicare P4P programs. “The AQA is charged with implementing performance measures and bringing them to the marketplace,” explains Dr. Torcson. “SHM is not involved in the AQA process yet.”

Membership in SHM means you are able to access the latest information on issues like CMS reporting initiatives and have representation in the decision-making process.

“I think it’s the responsibility of a professional society to not only be informed on what’s happening on a national level, but to have some influence,” says Dr. Torcson. “And SHM has done a great job in being well-positioned to influence the national agenda on quality and performance improvement.” TH

Jane Jerrard writes frequently for The Hospitalist.

On March 16, the John A. Hartford Foundation awarded SHM a $1.4 million grant to develop interventions to improve care transitions for older adults at the time of hospital discharge.

One of the core values of SHM and hospital medicine is to implement changes that improve the care older Americans receive. With this grant support from The Hartford Foundation, SHM can help define and set standards for best practices in discharge and provide a continuum of training opportunities to support those practices.

As part of this three-year project, SHM will partner with national leaders in care coordination to form a national advisory board, create clinical tools, implement guidelines, and provide technical support and training tools to hospitals across the U.S. The project aims to build capacity in at least 200 hospital sites to improve the discharge process and, ultimately, health outcomes for older adults.

Chapter Report

Los Angeles: The kick-off meeting for the Los Angeles chapter was held at Spago Beverly Hills on April 10. The meeting brought together approximately 25 physicians from eight hospitalist groups throughout Los Angeles County. Larry Wellikson, MD, CEO of SHM, gave a presentation, “The Emergence and Future of Hospital Medicine.” Dr. Wellikson illuminated many important points in his talk and encouraged attendees to become involved in quality improvement at their own hospitals. The meeting was supported by Ortho Biotech.

National Advisory Board AND Project Team

SHM has assembled a national advisory board to inform and guide the project. The board will be chaired by Eric Coleman, MD, MPH, associate professor of medicine within the divisions of healthcare policy and research and geriatric medicine at the University of Colorado Health Sciences Center in Aurora. At press time, members included:

• Barbara Berkman, DSW, PhD, professor of health and mental health, University School of Social Work, Mount Sinai School of Medicine;
• Tom Bookwalter, PharmD, clinical pharmacist, American Society of Health-System Pharmacists (ASHP);
• Alan Korn, MD, chief medical officer and senior vice president for clinical affairs, Blue Cross Blue Shield Association;
• Chuck Denham, MD, chair, National Quality Forum (NQF);
• Gavin Hougham, PhD, senior program officer, John A. Hartford Foundation;
• Seth Landefeld, MD, director, American Geriatrics Society (AGS);
• Cheri Lattimer, RN, BSN, executive director, Case Management Society of America (CMSA);
• William Lyons, MD, AGS; Nebraska Medical Center in Omaha;
• Lorraine Mion, PhD, RN, FAAN, director of nursing services for geriatrics, Metro Health Medical Center in Cleveland, Ohio;
• Mary Naylor, PhD, RN, FAANS, Marian S. Ware professor in gerontology, University of Pennsylvania;
• Gail Povar, MD, MPH, chair, George Washington School of Medicine, Cameron Medical Group;
• Deborah Queenan, national advisory council coordinator, Agency for Healthcare Research and Quality (AHRQ);
• Pat Rutherford, RN, MS, vice president, Institute for Healthcare Improvement (IHI), Transforming Care at the Bedside (TCAB);
• Eric Warm, MD, Society General Internal Medicine (SGIM); and
• Larry Wellikson, MD, CEO of SHM.

Dr. Williams will serve as principal investigator, leading a team of co-investigators including Jeffrey Greenwald, MD, (Boston University co-investigator, AHRQ, Project ReEngineering Discharge); Eric Howell, MD (Johns Hopkins Bayview, SHM/Hartford Safe Steps Demonstration Project); Param Dedhia, MD (Johns Hopkins Bayview, SHM/Hartford Safe STEPS Demonstration Project); Lakshmi Halasyamani, MD (St. Joseph Mercy Hospital); Kathleen Kerr (SHM); and Tina Budnitz, MPH (SHM).

The project team includes investigators from the SHM/Hartford Foundation Safe STEPS project and two AHRQ-funded projects. All three projects aim to pilot test discharge-planning toolkits and interventions and develop implementation strategies for adoption. The current project will leverage the findings of all three projects with the insights of the advisory board to create a transitions bundle to optimize the discharge process. Following development of this bundle, SHM will develop a toolkit for implementation with corresponding training programs, and other technical support.

click for large version

Capacity Building Via Continuum of Training Options

SHM has designed a range of technical support and training options to meet the needs of member institutions aiming to implement and sustain the transitions bundle. Strategies include:

• A Web-based resource room for care transitions in older adults: The transitions bundle, field guide, and related interventional materials will be freely available in the SHM online resource room.
• A Quality Pre-Course for QI Teams: The course is scheduled for 2008 and 2009 SHM Annual Meetings.
• A Transition Planning Mentored Implementation Program (TPMI): This yearlong mentoring program will support sites as they implement and evaluate transitions bundle interventions. The program includes a training conference, monthly teleconferences with expert mentors and peer support mechanisms.
• A consultation service: This will provide on-site consultation and technical assistance to sites planning, implementing, and evaluating discharge interventions. The service includes site visit, follow-up report of findings, recommendations and resources, and post-visit follow-up to review progress, successes and unforeseen barriers.

These support mechanisms are intended to assist those who lead improvement teams at their institutions. Enrollment will begin in the fall. For more information, contact tbudnitz@hospitalmedicine.org.

A Seat at the Table

SHM active in shaping new performance standards

By Jane Jerrard

Healthcare providers are in the midst of important changes in how they work and how they’re rewarded for that work. Recent initiatives including Medicare’s Physician Quality Reporting Initiative and a Medicare hospital value-based purchasing program mandated by the Deficit Reduction Act spell change for practitioners, including hospitalists.

SHM is working to add a hospitalist voice to discussions and decisions that shape these initiatives. By participating in organizations such as the American Medical Association’s (AMA) Physician consortium for Performance Improvement (PCPI), SHM has a seat at the table where decisions are made.

How Participation Works

The PCPI was convened in 2001 by the AMA, with the mission of physician-led performance improvement. While the primary focus is on improving quality, the Consortium’s performance measures are ultimately those used in CMS and other pay-for-performance (P4P) programs and value-based purchasing initiatives.

SHM didn’t get involved when the PCPI was first formed because the issues weren’t relevant to hospitalists. “SHM was invited to participate at that time, but the focus was really on outpatient care,” says Patrick J. Torcson, MD, MMM, FACP, director of hospital medicine at St. Tammany Parish Hospital in Covington, La. “More recently, when the PCPI began looking at the relation between hospital-level measures and physician-level measures, SHM CEO Larry Wellikson said we need to get involved.”

Dr. Torcson is SHM’s representative on the consortium. “For the last year and a half, I’ve been attending the PCPI meetings to represent SHM and have been involved in various PCPI work groups,” he says. “I had previously served on the SHM HQPS [Healthcare Quality and Patient Safety Task Force] and now serve on the PPC [Public Policy Committee], and I think the SHM leadership thought that combination of interests would be good for a PCPI representative.”

What about the Work Groups?

Work groups within the PCPI are assigned specific areas. These groups are responsible for creating performance measures within an area, which are then reviewed by the entire consortium.

“I participated on a work group to develop performance measures for emergency medicine physicians,” says Dr. Torcson. “This group thought that the current disease-specific measures weren’t relevant for them, and that the current hospital measures were also not relevant. I provided a hospitalist’s perspective on hand-offs and discharge which was really focused on a process of care that begins in the ED [emergency department].”

Each work group has representation from various areas of healthcare. “My work group had about 20 or 25 people, which is probably typical,” says Dr. Torcson. “The AMA provided a methodologist, and there was a CMS representative on the work group.” The work group first met face to face to review relevant evidence-based clinical guidelines and scame up with five to eight measures. These were then reworked through phone calls and e-mails before going before the entire PCPI for approval.

Other SHM representatives participated in relevant PCPI work groups as well. “PPC member Greg Seymann from San Diego participated in a geriatric work group that was convened for the same reason” as the ED group, says Dr. Torcson. “His group looked at creating a number of measures that were relative to both inpatient and outpatient geriatric patients. Some of these measures are now part of the Medicare Physician Quality Reporting Initiative.”

Another SHM member, James C. Pile. MD, FACP, participated in a work group on developing measures for outpatient administration of IV antibiotics. Pile is a staff physician in the Department of General Internal Medicine, Section of Hospital Medicine, at The Cleveland Clinic in Ohio.

In each group, SHM representatives were able to help shape measures that reflect the unique knowledge and perspective of hospital medicine.

“A hospitalist brings the perspective of having seen how these measures are actually incorporated into a practice, how they are actually applied to patient care,” Dr. Torcson points out. “These work groups to develop additional performance measures are ongoing. The PCPI has a rigorous agenda for what they want to accomplish over the next few years.”

SHM to Lead the Way on Care Transitions

The PCPI has asked SHM to be the lead organization for a performance measure development work group on care coordination and care transitions.

“This will be groundbreaking work around this important aspect of care that is very process-focused as opposed to disease-focused,” says Dr. Torcson. “It’s very appropriate that SHM was asked to be the lead group for this. This area of performance improvement is perfect for what hospitalists do.”

The PCPI plans to have care transition performance measures ready for adoption by 2009.

SHM and the Big Three

CMS is also collaborating with the National Quality Forum (NQF) and Ambulatory Quality Alliance (AQA). “The PCPI, AQA, and NQF are the most influential organizations right now for quality and performance measures,” says Dr. Torcson.

The NQF, a unique public and private collaborative, develops consensus standards on different measures submitted to it. “I have had the opportunity to participate on an NQF Steering Committee for performance measure endorsement,” says Dr. Torcson.

The AQA is responsible for standardizing performance measurement and reporting, and developing measures for efficiency to be included in forthcoming Medicare P4P programs. “The AQA is charged with implementing performance measures and bringing them to the marketplace,” explains Dr. Torcson. “SHM is not involved in the AQA process yet.”

Membership in SHM means you are able to access the latest information on issues like CMS reporting initiatives and have representation in the decision-making process.

“I think it’s the responsibility of a professional society to not only be informed on what’s happening on a national level, but to have some influence,” says Dr. Torcson. “And SHM has done a great job in being well-positioned to influence the national agenda on quality and performance improvement.” TH

Jane Jerrard writes frequently for The Hospitalist.

On March 16, the John A. Hartford Foundation awarded SHM a $1.4 million grant to develop interventions to improve care transitions for older adults at the time of hospital discharge.

One of the core values of SHM and hospital medicine is to implement changes that improve the care older Americans receive. With this grant support from The Hartford Foundation, SHM can help define and set standards for best practices in discharge and provide a continuum of training opportunities to support those practices.

As part of this three-year project, SHM will partner with national leaders in care coordination to form a national advisory board, create clinical tools, implement guidelines, and provide technical support and training tools to hospitals across the U.S. The project aims to build capacity in at least 200 hospital sites to improve the discharge process and, ultimately, health outcomes for older adults.

Chapter Report

Los Angeles: The kick-off meeting for the Los Angeles chapter was held at Spago Beverly Hills on April 10. The meeting brought together approximately 25 physicians from eight hospitalist groups throughout Los Angeles County. Larry Wellikson, MD, CEO of SHM, gave a presentation, “The Emergence and Future of Hospital Medicine.” Dr. Wellikson illuminated many important points in his talk and encouraged attendees to become involved in quality improvement at their own hospitals. The meeting was supported by Ortho Biotech.

National Advisory Board AND Project Team

SHM has assembled a national advisory board to inform and guide the project. The board will be chaired by Eric Coleman, MD, MPH, associate professor of medicine within the divisions of healthcare policy and research and geriatric medicine at the University of Colorado Health Sciences Center in Aurora. At press time, members included:

• Barbara Berkman, DSW, PhD, professor of health and mental health, University School of Social Work, Mount Sinai School of Medicine;
• Tom Bookwalter, PharmD, clinical pharmacist, American Society of Health-System Pharmacists (ASHP);
• Alan Korn, MD, chief medical officer and senior vice president for clinical affairs, Blue Cross Blue Shield Association;
• Chuck Denham, MD, chair, National Quality Forum (NQF);
• Gavin Hougham, PhD, senior program officer, John A. Hartford Foundation;
• Seth Landefeld, MD, director, American Geriatrics Society (AGS);
• Cheri Lattimer, RN, BSN, executive director, Case Management Society of America (CMSA);
• William Lyons, MD, AGS; Nebraska Medical Center in Omaha;
• Lorraine Mion, PhD, RN, FAAN, director of nursing services for geriatrics, Metro Health Medical Center in Cleveland, Ohio;
• Mary Naylor, PhD, RN, FAANS, Marian S. Ware professor in gerontology, University of Pennsylvania;
• Gail Povar, MD, MPH, chair, George Washington School of Medicine, Cameron Medical Group;
• Deborah Queenan, national advisory council coordinator, Agency for Healthcare Research and Quality (AHRQ);
• Pat Rutherford, RN, MS, vice president, Institute for Healthcare Improvement (IHI), Transforming Care at the Bedside (TCAB);
• Eric Warm, MD, Society General Internal Medicine (SGIM); and
• Larry Wellikson, MD, CEO of SHM.

Dr. Williams will serve as principal investigator, leading a team of co-investigators including Jeffrey Greenwald, MD, (Boston University co-investigator, AHRQ, Project ReEngineering Discharge); Eric Howell, MD (Johns Hopkins Bayview, SHM/Hartford Safe Steps Demonstration Project); Param Dedhia, MD (Johns Hopkins Bayview, SHM/Hartford Safe STEPS Demonstration Project); Lakshmi Halasyamani, MD (St. Joseph Mercy Hospital); Kathleen Kerr (SHM); and Tina Budnitz, MPH (SHM).

The project team includes investigators from the SHM/Hartford Foundation Safe STEPS project and two AHRQ-funded projects. All three projects aim to pilot test discharge-planning toolkits and interventions and develop implementation strategies for adoption. The current project will leverage the findings of all three projects with the insights of the advisory board to create a transitions bundle to optimize the discharge process. Following development of this bundle, SHM will develop a toolkit for implementation with corresponding training programs, and other technical support.

click for large version

Capacity Building Via Continuum of Training Options

SHM has designed a range of technical support and training options to meet the needs of member institutions aiming to implement and sustain the transitions bundle. Strategies include:

• A Web-based resource room for care transitions in older adults: The transitions bundle, field guide, and related interventional materials will be freely available in the SHM online resource room.
• A Quality Pre-Course for QI Teams: The course is scheduled for 2008 and 2009 SHM Annual Meetings.
• A Transition Planning Mentored Implementation Program (TPMI): This yearlong mentoring program will support sites as they implement and evaluate transitions bundle interventions. The program includes a training conference, monthly teleconferences with expert mentors and peer support mechanisms.
• A consultation service: This will provide on-site consultation and technical assistance to sites planning, implementing, and evaluating discharge interventions. The service includes site visit, follow-up report of findings, recommendations and resources, and post-visit follow-up to review progress, successes and unforeseen barriers.

These support mechanisms are intended to assist those who lead improvement teams at their institutions. Enrollment will begin in the fall. For more information, contact tbudnitz@hospitalmedicine.org.

A Seat at the Table

SHM active in shaping new performance standards

By Jane Jerrard

Healthcare providers are in the midst of important changes in how they work and how they’re rewarded for that work. Recent initiatives including Medicare’s Physician Quality Reporting Initiative and a Medicare hospital value-based purchasing program mandated by the Deficit Reduction Act spell change for practitioners, including hospitalists.

SHM is working to add a hospitalist voice to discussions and decisions that shape these initiatives. By participating in organizations such as the American Medical Association’s (AMA) Physician consortium for Performance Improvement (PCPI), SHM has a seat at the table where decisions are made.

How Participation Works

The PCPI was convened in 2001 by the AMA, with the mission of physician-led performance improvement. While the primary focus is on improving quality, the Consortium’s performance measures are ultimately those used in CMS and other pay-for-performance (P4P) programs and value-based purchasing initiatives.

SHM didn’t get involved when the PCPI was first formed because the issues weren’t relevant to hospitalists. “SHM was invited to participate at that time, but the focus was really on outpatient care,” says Patrick J. Torcson, MD, MMM, FACP, director of hospital medicine at St. Tammany Parish Hospital in Covington, La. “More recently, when the PCPI began looking at the relation between hospital-level measures and physician-level measures, SHM CEO Larry Wellikson said we need to get involved.”

Dr. Torcson is SHM’s representative on the consortium. “For the last year and a half, I’ve been attending the PCPI meetings to represent SHM and have been involved in various PCPI work groups,” he says. “I had previously served on the SHM HQPS [Healthcare Quality and Patient Safety Task Force] and now serve on the PPC [Public Policy Committee], and I think the SHM leadership thought that combination of interests would be good for a PCPI representative.”

What about the Work Groups?

Work groups within the PCPI are assigned specific areas. These groups are responsible for creating performance measures within an area, which are then reviewed by the entire consortium.

“I participated on a work group to develop performance measures for emergency medicine physicians,” says Dr. Torcson. “This group thought that the current disease-specific measures weren’t relevant for them, and that the current hospital measures were also not relevant. I provided a hospitalist’s perspective on hand-offs and discharge which was really focused on a process of care that begins in the ED [emergency department].”

Each work group has representation from various areas of healthcare. “My work group had about 20 or 25 people, which is probably typical,” says Dr. Torcson. “The AMA provided a methodologist, and there was a CMS representative on the work group.” The work group first met face to face to review relevant evidence-based clinical guidelines and scame up with five to eight measures. These were then reworked through phone calls and e-mails before going before the entire PCPI for approval.

Other SHM representatives participated in relevant PCPI work groups as well. “PPC member Greg Seymann from San Diego participated in a geriatric work group that was convened for the same reason” as the ED group, says Dr. Torcson. “His group looked at creating a number of measures that were relative to both inpatient and outpatient geriatric patients. Some of these measures are now part of the Medicare Physician Quality Reporting Initiative.”

Another SHM member, James C. Pile. MD, FACP, participated in a work group on developing measures for outpatient administration of IV antibiotics. Pile is a staff physician in the Department of General Internal Medicine, Section of Hospital Medicine, at The Cleveland Clinic in Ohio.

In each group, SHM representatives were able to help shape measures that reflect the unique knowledge and perspective of hospital medicine.

“A hospitalist brings the perspective of having seen how these measures are actually incorporated into a practice, how they are actually applied to patient care,” Dr. Torcson points out. “These work groups to develop additional performance measures are ongoing. The PCPI has a rigorous agenda for what they want to accomplish over the next few years.”

SHM to Lead the Way on Care Transitions

The PCPI has asked SHM to be the lead organization for a performance measure development work group on care coordination and care transitions.

“This will be groundbreaking work around this important aspect of care that is very process-focused as opposed to disease-focused,” says Dr. Torcson. “It’s very appropriate that SHM was asked to be the lead group for this. This area of performance improvement is perfect for what hospitalists do.”

The PCPI plans to have care transition performance measures ready for adoption by 2009.

SHM and the Big Three

CMS is also collaborating with the National Quality Forum (NQF) and Ambulatory Quality Alliance (AQA). “The PCPI, AQA, and NQF are the most influential organizations right now for quality and performance measures,” says Dr. Torcson.

The NQF, a unique public and private collaborative, develops consensus standards on different measures submitted to it. “I have had the opportunity to participate on an NQF Steering Committee for performance measure endorsement,” says Dr. Torcson.

The AQA is responsible for standardizing performance measurement and reporting, and developing measures for efficiency to be included in forthcoming Medicare P4P programs. “The AQA is charged with implementing performance measures and bringing them to the marketplace,” explains Dr. Torcson. “SHM is not involved in the AQA process yet.”

Membership in SHM means you are able to access the latest information on issues like CMS reporting initiatives and have representation in the decision-making process.

“I think it’s the responsibility of a professional society to not only be informed on what’s happening on a national level, but to have some influence,” says Dr. Torcson. “And SHM has done a great job in being well-positioned to influence the national agenda on quality and performance improvement.” TH

Jane Jerrard writes frequently for The Hospitalist.

A70-year-old female was admitted for management of progressive cellulitis and evaluation of a lower leg laceration after she fell from a motorized scooter. She had initially failed outpatient management with cephalexin and was treated with vancomycin and piperacillin and tazobactam while hospitalized. Her cellulitis resolved, and plastic surgery helped repair the laceration with skin grafting from her right thigh.

Three days after the procedure, the woman’s electrolyte panel read plasma glucose 110 mg/dL, blood urea nitrogen 11 mg/dL, serum creatinine 0.8 mg/dL, sodium 138 mEq/L, potassium 5.7 mEq/L, chloride 101 mEq/L, bicarbonate 28 mEq/L, magnesium 2.1 mg/dl, and calcium 8.9 mg/dl.

She was taking:

• Citalopram 20 mg PO QD;
• HCTZ 25 mg PO QD;
• Docusate 100 mg PO twice daily;
• Oxycodone 5 mg PO Q6 hours PRN pain;
• Acetaminophen 500 mg PO Q6 hours scheduled;
• Heparin 5,000 units SQ q eight hours;
• Levothyroxine 25 mcg PO QAM;
• Intravenous fluid D5NS at 80 cc/hour; and
• Trazodone 50 mg PO PRN insomnia.

Her urinalysis showed:

• pH 6.8;
• Na 155 meq/L;
• K 20 meq/L; and
• Urine osmolality 447.

Which of the following is the most appropriate action for this patient?

a) Sodium polystyrene sulfonate 30 gm orally every 4 hours; four doses

b) Sodium polystyrene sulfonate enema 60 gm

c) Discontinue citalopram

d) Discontinue oxycodone

e) Discontinue heparin

Discussion

The answer is E: Discontinue heparin. This patient has hyperkalemia with low urinary excretion of potassium and no evidence of acidosis. Many medications can cause hyperkalemia, most notably angiotensin-converting enzyme inhibitors, K-sparing diuretics, NSAIDs, and beta-blockers.

When an obvious cause is not present, such as over-supplementation of potassium chloride via oral or intravenous route, a search for less obvious causes, such as renal tubular acidosis, is warranted. In this patient none of these causes is present.

Heparin has many potential side effects, both directly from anticoagulation, such as retroperitoneal hemorrhage, or immunologically, such as heparin-induced thrombocytopenia (HIT). In this case the patient has heparin-induced hypoaldosteronism causing secondary hyperkalemia. This can occur with all types of heparin, usually at doses greater then 5,000 units/day. This emphasizes the point that when an unexpected phenomenon is noted in a hospitalized patient, a search should always include medications’ side effects.

Subcutaneous heparin was discontinued, and the patient was placed on aspirin, TED hose stockings, and sequential compression devices for deep vein thrombosis (DVT) prophylaxis. A repeat electrolyte panel obtained afterward showed resolution of the patient’s hyperkalemia. TH

Dr. Newman and Herber practice at the Department of Medicine, Mayo Graduate School of Medical Education, Mayo Clinic, Rochester, Minn.

A70-year-old female was admitted for management of progressive cellulitis and evaluation of a lower leg laceration after she fell from a motorized scooter. She had initially failed outpatient management with cephalexin and was treated with vancomycin and piperacillin and tazobactam while hospitalized. Her cellulitis resolved, and plastic surgery helped repair the laceration with skin grafting from her right thigh.

Three days after the procedure, the woman’s electrolyte panel read plasma glucose 110 mg/dL, blood urea nitrogen 11 mg/dL, serum creatinine 0.8 mg/dL, sodium 138 mEq/L, potassium 5.7 mEq/L, chloride 101 mEq/L, bicarbonate 28 mEq/L, magnesium 2.1 mg/dl, and calcium 8.9 mg/dl.

She was taking:

• Citalopram 20 mg PO QD;
• HCTZ 25 mg PO QD;
• Docusate 100 mg PO twice daily;
• Oxycodone 5 mg PO Q6 hours PRN pain;
• Acetaminophen 500 mg PO Q6 hours scheduled;
• Heparin 5,000 units SQ q eight hours;
• Levothyroxine 25 mcg PO QAM;
• Intravenous fluid D5NS at 80 cc/hour; and
• Trazodone 50 mg PO PRN insomnia.

Her urinalysis showed:

• pH 6.8;
• Na 155 meq/L;
• K 20 meq/L; and
• Urine osmolality 447.

Which of the following is the most appropriate action for this patient?

a) Sodium polystyrene sulfonate 30 gm orally every 4 hours; four doses

b) Sodium polystyrene sulfonate enema 60 gm

c) Discontinue citalopram

d) Discontinue oxycodone

e) Discontinue heparin

Discussion

The answer is E: Discontinue heparin. This patient has hyperkalemia with low urinary excretion of potassium and no evidence of acidosis. Many medications can cause hyperkalemia, most notably angiotensin-converting enzyme inhibitors, K-sparing diuretics, NSAIDs, and beta-blockers.

When an obvious cause is not present, such as over-supplementation of potassium chloride via oral or intravenous route, a search for less obvious causes, such as renal tubular acidosis, is warranted. In this patient none of these causes is present.

Heparin has many potential side effects, both directly from anticoagulation, such as retroperitoneal hemorrhage, or immunologically, such as heparin-induced thrombocytopenia (HIT). In this case the patient has heparin-induced hypoaldosteronism causing secondary hyperkalemia. This can occur with all types of heparin, usually at doses greater then 5,000 units/day. This emphasizes the point that when an unexpected phenomenon is noted in a hospitalized patient, a search should always include medications’ side effects.

Subcutaneous heparin was discontinued, and the patient was placed on aspirin, TED hose stockings, and sequential compression devices for deep vein thrombosis (DVT) prophylaxis. A repeat electrolyte panel obtained afterward showed resolution of the patient’s hyperkalemia. TH

Dr. Newman and Herber practice at the Department of Medicine, Mayo Graduate School of Medical Education, Mayo Clinic, Rochester, Minn.

A70-year-old female was admitted for management of progressive cellulitis and evaluation of a lower leg laceration after she fell from a motorized scooter. She had initially failed outpatient management with cephalexin and was treated with vancomycin and piperacillin and tazobactam while hospitalized. Her cellulitis resolved, and plastic surgery helped repair the laceration with skin grafting from her right thigh.

Three days after the procedure, the woman’s electrolyte panel read plasma glucose 110 mg/dL, blood urea nitrogen 11 mg/dL, serum creatinine 0.8 mg/dL, sodium 138 mEq/L, potassium 5.7 mEq/L, chloride 101 mEq/L, bicarbonate 28 mEq/L, magnesium 2.1 mg/dl, and calcium 8.9 mg/dl.

She was taking:

• Citalopram 20 mg PO QD;
• HCTZ 25 mg PO QD;
• Docusate 100 mg PO twice daily;
• Oxycodone 5 mg PO Q6 hours PRN pain;
• Acetaminophen 500 mg PO Q6 hours scheduled;
• Heparin 5,000 units SQ q eight hours;
• Levothyroxine 25 mcg PO QAM;
• Intravenous fluid D5NS at 80 cc/hour; and
• Trazodone 50 mg PO PRN insomnia.

Her urinalysis showed:

• pH 6.8;
• Na 155 meq/L;
• K 20 meq/L; and
• Urine osmolality 447.

Which of the following is the most appropriate action for this patient?

a) Sodium polystyrene sulfonate 30 gm orally every 4 hours; four doses

b) Sodium polystyrene sulfonate enema 60 gm

c) Discontinue citalopram

d) Discontinue oxycodone

e) Discontinue heparin

Discussion

The answer is E: Discontinue heparin. This patient has hyperkalemia with low urinary excretion of potassium and no evidence of acidosis. Many medications can cause hyperkalemia, most notably angiotensin-converting enzyme inhibitors, K-sparing diuretics, NSAIDs, and beta-blockers.

When an obvious cause is not present, such as over-supplementation of potassium chloride via oral or intravenous route, a search for less obvious causes, such as renal tubular acidosis, is warranted. In this patient none of these causes is present.

Heparin has many potential side effects, both directly from anticoagulation, such as retroperitoneal hemorrhage, or immunologically, such as heparin-induced thrombocytopenia (HIT). In this case the patient has heparin-induced hypoaldosteronism causing secondary hyperkalemia. This can occur with all types of heparin, usually at doses greater then 5,000 units/day. This emphasizes the point that when an unexpected phenomenon is noted in a hospitalized patient, a search should always include medications’ side effects.

Subcutaneous heparin was discontinued, and the patient was placed on aspirin, TED hose stockings, and sequential compression devices for deep vein thrombosis (DVT) prophylaxis. A repeat electrolyte panel obtained afterward showed resolution of the patient’s hyperkalemia. TH

Dr. Newman and Herber practice at the Department of Medicine, Mayo Graduate School of Medical Education, Mayo Clinic, Rochester, Minn.