American College of Physicians: Internal Medicine — Doctors for Adults ®

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Friday, January 23, 2015

3 highly effective ways to reduce readmissions

The enormous push continues to reduce readmissions, due in no small part to stiff financial penalties from CMS for the worst performing hospitals. The most commonly cited statistic is that about 1 in 5, or 20 percent, of Medicare patients are readmitted within 30 days. A staggeringly high number when you think about it. Having discharged thousands of patients and seen the characteristics of those patients that are frequently readmitted (who are unfortunately called “frequent flyers” in hospital circles), here are my 3 ways to help solve the problem:

1. Focused targeting

When we talk about readmissions, the first step is to identify those patients who are at the highest risk of coming straight back into the hospital. It's a mix of socioeconomic status, demographics, social support, education, and most importantly baseline co-morbidities and functional status. If your readmission program targets “everyone”, it will expend too much energy on the vast majority of people who don't get readmitted. Employing Pareto's principle (see my previous article); remember that 80% or more readmissions will come from 20% or less of the same patients.

2. Discharge process

Discharging a patient in the typical rushed environment of a hospital is too often haphazard and disjointed. This is the one chance to make sure that all the paperwork and instructions are as thorough and comprehensive as possible. Exhaustively educate the patient and family. It should be the physician that leads this process. Much is made of a discharge taking at least 30 minutes—but perhaps even an hour would be a better time.

The problem with this? It's not as simple as it sounds. In the real word of economic pressures for both doctors and hospitals, spending an hour with every patient you discharge isn't really possible (that's not just a problem for U.S. medicine, because socialized countries in fact usually see more patients in even less time).

3. Intense primary care

Studies may show differing results, but I can tell you with certainty that patients with strong primary care follow-up and outpatient monitoring are definitely less likely to be readmitted. Make sure those high-risk patients have close follow-up ideally within a day or two of exiting the hospital.

The drive to reduce readmissions is a noble one. But we have to be realistic too. With an ageing population, this issue is going to remain at the forefront. The nature of illness is that it's a fragile time for our patients, and particularly for those with chronic underlying illnesses such as COPD or congestive heart failure. It doesn't take much to push things over the edge and for people to be sick enough to require a hospital bed. Battling nature can be hard. The question is: how can we best minimize the likelihood of the next setback and continue to keep more and more people out of hospital and in the comforts of their own home?

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.

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Monday, January 19, 2015

Shared accountability

There are plenty of good reasons why thoughtful physicians are often unhappy with the current approach to measuring the quality of care they provide. Some, of course, object to the whole notion of quality measurement, but I believe they are in a shrinking minority clinging to an anachronistic mental model in which each physician defines for himself what constitutes high quality care. I have addressed this previously. But even those, who like me, believe it is essential (and possible) to measure quality, can point to legitimate shortcomings in the way it is done.

Among these shortcomings is the imperfect process by which individual physicians' “results” are “adjusted” to account for differences in the patients they care for. In the simplest case, when the quality of care is judged by looking at patient outcomes, this risk-adjustment is meant to reflect the fact that clinical outcomes reflect both the baseline characteristics of the patients being treated and the treatment they get. For example, if one were to use in-hospital mortality rates to assess the quality of care for acute myocardial infarction, it would be essential to know “how sick” the patients, on average, were on presentation. A 50-year-old man with a small inferior wall MI is likely to live even in the absence of good care (or any care for that matter), whereas a 90-year-old woman with cardiogenic shock from an anterior wall MI is likely to die even with state-of-the art care. Any attempt to assess the quality of care for a population of MI patients must take this into consideration.

There is a more subtle way in which patient characteristics play into quality measurement schemes, even when the measurements are about processes of care instead of patient outcomes. In this construct, providers are assessed by how often patients eligible for some service or intervention actually get it. Did the patients with diabetes get fundoscopic exams? Did the women in their 50s get mammograms? Are the patients with coronary heart disease all on aspirin? Here it is easy to prospectively define exclusion criteria, which are meant to mimic reasonable clinical decision-making, and shield the provider from a “grade” that really reflects unmeasured differences in patient populations. For example, it would not be reasonable (or be indicative of high quality care!) to give aspirin to a patient with an aspirin allergy, so patients with aspirin allergy are excluded from the denominator, and the provider is not judged harshly for a “failure” to prescribe it. So far, so good. This gets a whole lot trickier, however, when trying to figure out how to handle instances where care is recommended, but not done. What happens if the patient is advised that she should have that mammogram, but doesn't get it?

Assuming for a moment that it is possible to accurately distinguish between a failure (on the part of the physician) to recommend and a failure (on the part of the patient) to adhere to the physician's recommendation, who is responsible for the latter? On the one hand, it seems pretty straightforward: the “right” care was recommended, and the patient failed to take good advice, so this can't possibly be used to judge the care the doctor provided, right? Well, maybe so, but maybe the patient didn't take the recommended course of action because the doctor failed to explain it in a way the patient understood, or because the patient couldn't access the recommended service, or because the patient experienced a side-effect that the physician did not elicit. In these instances, accountability is shared by patients and their physicians.

This idea of shared accountability was recently addressed by a joint committee of the American College of Cardiology and the American Heart Association. These organizations have been collaborating for years to produce clinical practice guidelines. The guidelines, in turn, have been used as the basis for a wide range of performance measures, which have been used to assess the quality of cardiovascular care. The published “statement” is a thoughtful consideration of how to balance the interdependent responsibilities of clinicians, patients and systems of care. I urge you to read the whole thing. Once you do, let me know what you think.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.

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Friday, January 16, 2015

How information technology has made health care (just a little bit) better

Health care information technology really has a long way to go before it lives up to its promise of truly improving healthcare. Having written a lot about the pitfalls (which I will continue to do, because it's important we address them) including reduced efficiency, less thoughtful medicine, and worst of all decreased human contact with our patients—I thought I would write about where IT has actually made things a little better.

I had a conversation at a hospital medicine meeting recently with a former colleague, a wonderful Chief of Hospital medicine who served as my mentor when I first became an Attending physician. I was telling her my thoughts on the suboptimal state of health care IT, and while she agreed, she then started telling me about how she thought the changes over the last several years may have actually improved hospital medicine in several ways as well. We discussed this in detail, and yes, it made me reflect on the fact that there are many good things along with the bad. Here are some of them:

1. No more paper charts

Who can ever forget those days of trawling through dozens of paper charts to get that elusive information we needed? Computers save so much time when you're searching for certain documented notes and test results. Furthermore, paper charts are also hard to locate on hospital floors, and doctors would often need to circle the unit several times to find it! Nowadays—just go right to any computer to access the chart. Not to mention it's much better for the environment as well to not to be using so much paper.

2. No more hand written forms

In the past, admitting a patient to hospital would mean that the doctor or nurse had to manually fill out reams of paper forms. Not anymore.

3. Remote access

Paper charts meant that the doctor would have to physically go to the specific unit to look at the information they required. Now this can be done from any computer in the hospital and even from your own home if doctors are called late in the evening.

4. No more doctors' handwriting issues

Enough said, we all have a story here to tell. The days of unit secretaries asking everyone on the floor: “What does this medicine look like to you?—are over.

5. Clearer doctors' orders via computerized entry

Fewer ambiguous orders that may not reflect best practice standards or correct medication dosages.

The above 5 points are worth reflecting on every time physicians and nurses (understandably) feel frustrated by some of the current crop of unwieldy and inefficient systems. If we can just make these better, magnifying the obvious good and minimizing the very apparent bad—while keeping human contact at the heart of health care—we will be on the right track.

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.

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Monday, January 12, 2015

Residency ratings

I have been a big proponent of seeking the feedback of our patients regarding their experiences with our care, and of pushing our organization to be more transparent about the results. I believe that sharing performance motivates everyone to raise his game, and that we should embrace valid ratings on specific measures. On the other hand, I have always thought that global “rankings” divorced from specific performance measures make little sense.

As Malcolm Gladwell pointed out in the New Yorker a few years ago rankings of complex, multidimensional things like cars or colleges are inevitably flawed, because they don't account for the fact that different people will value various attributes in different ways. There is no “best car” since I may value handling and acceleration, and you may value styling and safety. Likewise, there is no “best college” because one student may value class size or athletic facilities while another values research opportunities and proximity to a large city.
That is why I was appalled when I got an email from the current director of my old medical residency. Here is what is wrong with this, in no particular order.

Like cars and colleges, residency programs have too many dimensions to reduce to a simple comparative rank. Doing so ignores of host of questions that may be important to a graduating medical student, such as: Is this in a city where you would like to settle? Does the institution have strength in a particular subspecialty that you may want to pursue? Will you be required to travel to satellite training sites? If so, would you consider that an asset or a deficiency?

Technically, I am not an “alum” of the BIDMC training program. I am proud to say I did my medicine residency at Boston's Beth Israel Hospital, which no longer exists. The BIDMC was created years later through the merger of the BI and the New England Deaconess Hospital.

Even if the old BI did exist, what could I possibly contribute to developing an accurate assessment of the current program, given that I was an intern 30 years ago?

This has nothing to do with seeking meaningful feedback to drive improvement. It has everything to do with soliciting votes for a beauty contest.

In the end, this is pretty sad. I think my residency program was very good. I cared for a wide range of patients, I had excellent role models, and I developed skills and habits that provided an excellent foundation for my professional growth and development. I also developed a deep affection for the hospital where I trained; it is not only where I trained, but where I later met my wife, and where our children were born. And yet all of that is, in the end, completely irrelevant. So I won't be “voting” for this program on Doximity, and I hope no one else will either.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.

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Friday, January 9, 2015

Pareto's Principle in hospital medicine

There are certain universal laws that appear to govern the broader workings of the world around us. For those of you unfamiliar with Pareto's Principle, it's a concept that was first applied in economics and then found to be a governing rule in a whole host of different arenas. It's no understatement to say that understanding and acting upon this concept can be transformative, not just in your work but also your personal life.

Pareto's Principle also has become a popular area of focus in the world of business and management. Named after the 19th century Italian economist Vilfredo Pareto, in a nutshell the principle is as follows: 80% of effects always come from 20% of the causes. Pareto first observed this ratio when he realized that 80% of land and wealth in Italy was owned by 20% of the population. He then went on to observe the same phenomenon in his garden—80% of peas came from 20% of pea pods!

Since he published these findings, the magical ratio of 80-20 (or the “80-20 Rule”) has been found to be scattered throughout society and nature: 80% of any company's profits come from 20% of their best products; 80% of traffic comes from 20% of roads; 80% of food production comes from 20% of the best crops. The ratio is everywhere—frequently even tipped to a 90-10 or 95-5 division. However the 80-20 phenomenon is the distribution most often cited as a universal baseline. That being the case, I thought I would apply Pareto's Principle to the practice of hospital medicine:
• 80% of the clinical and problematic issues on any given day will arise from 20% of your patients
• 80% of telephone calls and pages will always come from 20% of nurses
• 80% of valuable medical information that you receive will come from only 20% of what's communicated to you
• 80% of your job satisfaction will come from 20% of your daily interactions
• 80% of compliments that your group receives will be about the good work of 20% of your physicians, and conversely 80% of complaints will be about 20% of your physicians!

How are these statistics even relevant to the daily grind? Well, by recognizing Pareto's Principle we can set realistic expectations and focus on the most important areas to make our jobs more productive and satisfying. We can reverse the 80-20 equation to ask questions such as:
• which 20% of patients are going to take up 80% of my effort?
• which 20% of colleagues are responsible for 80% of what makes my work environment enjoyable?
• which 20% of my time is giving me 80% of my job satisfaction?
• which 20% of work-related issues are responsible for 80% of my job dissatisfaction?

Of course the 80-20 percentage is not absolute, but it can act as a broad starting point of awareness in order to stand a better chance of improving things. Furthermore, remembering Pareto's Principle can also save us from what I call “casting the net too wide syndrome”. For example, when I have sat on committees addressing problems such as readmissions, solutions are proposed which are all encompassing and don't adequately target who we should be. If 80% of readmissions come from 20% or less of the same congestive heart failure patients, then we should understand the characteristics of these 20% before we put excess effort into stopping readmissions among the 80% of patients who are very unlikely to be readmitted in the first place.

Another example: If we want to reduce unnecessary daily laboratory testing—who are the 20% of patients that this applies to the most? It will usually be those patients with longer lengths of stay who may have multiple transitions and handoffs within the hospital. If we target all patients, we will expend too much energy addressing a problem that may not have existed in 80% of patients!

Applying the principle to our daily interactions in hospital medicine, if there are complaints about “specialist communication” or “soft admissions” from the emergency room, who are the 20% of physicians responsible for 80% of this? Let's shift the focus on them instead of making blanket statements about how bad the situation may be.

Acknowledging the value of and employing Pareto's Principle can help guide us through our days and even our careers. Only when we hone in on this natural distribution can we then do our best to skew it in our favor, and have an impact on better systems and practices.

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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