Published in the March 2004 issue of Today’s Hospitalist
Since 1989, the Agency for Healthcare Research and Quality (AHRQ) has led the federal government’s efforts to research ways to improve the quality of American health care. With an annual budget of nearly $300 million and a mandate from the Department of Health and Human Services (HHS) to advance evidence-based medicine, AHRQ is on a mission to improve patient safety and the quality of care.
This year for the first time, a hospitalist will play a key role in steering AHRQ’s quality improvement efforts. Andrew Fishmann, MD, is a California-based hospitalist and a founding member of Cogent Healthcare, a for-profit hospitalist management company. Late last year, he was named to a three-year term on AHRQ’s national advisory council, which advises the agency about its health services agenda.
The council consists of 21 private-sector members and ex-officio members that include representatives from the CDC and the National Institutes of Health. Members include high-profile physicians like JCAHO president Dennis O’Leary, MD, as well as leaders from academic medicine, public health and the drug industry.
The 53-year old Dr. Fishmann is a pulmonary and critical care specialist who practices full-time inpatient medicine at Good Samaritan Hospital in Los Angeles. He spends one week every other month mentoring hospitalists on-site in one of the 13 hospital systems around the country where Cogent has been hired to manage hospitalist programs.
Dr. Fishmann says his appointment is one result of the government’s growing interest in the impact of hospitalists on health care outcomes. He also cites Cogent’s track record of implementing best practice guidelines in hospitalist programs and using data to improve quality.
Dr. Fishmann talked to Today’s Hospitalist about the opportunities his new appointment may present for hospitalist medicine.
How did your appointment to AHRQ’s national advisory council come about?
I approached officials from the Bush administration last year to explain the growing trend of inpatient medicine and ask if there was any way I could help. Former CMS administrator Tom Scully was the guest speaker at a Cogent forum, so he was aware of the hospitalist movement, as was HHS Secretary Thompson.
Is your appointment a sign that hospitalists have arrived in terms of national policy-making?
We’ve arrived, but I’m not sure that the government is trying to integrate us into federal programs. I think federal officials are looking for data to figure out what role we should play, so my plea to hospitalists is to submit data to the government. I think getting the government involved in the hospitalist movement is a crucial step for our specialty, but it won’t happen if we don’t make our case with data.
What type of data does the government need on hospitalists?
We know within our own organizations that hospitalists save money, improve quality and devise protocols that work. But as you look at the government’s quality and disparity reports, it’s clear that there are very little data from hospitals.
For example, Cogent has data showing that hospitalists’ rate of treating MI patients with beta-blockers is much higher than the national average, and that our lengths of stay and risk of infections are lower. Those are the kinds of data the government needs in order to say, “We can apply these data across the board to improve quality, reduce risk and save money.” Money is going to be a much greater limiting factor over the next several years.
I hope that over the next several months “not years, but months “that the government will look at hospitalists as a rapidly growing, expanding specialty that already has 8,000 physicians practicing in more than 30% of the facilities in the United States. I think they’ll understand that interacting with a select group of physicians “not the 500,000 doctors who practice in the outpatient world “is the best way to get the message across.
Hospitalists make up a small sub-segment of doctors who control the greatest number of health care dollars spent because they deal with hospitalized patients. Hospitalists also deal with end-of-life issues, and the greatest amount of dollars spent is in the last several months of life.
What concerns do federal agencies have in terms of inpatient care?
The government knows that there are disparities in hospital care from state to state, from men to women and from African Americans to whites. And the government has demonstrated that only 40% of patients who smoke are given advice on cessation when they leave the hospital. They know that many patients don’t get diabetic counseling or vaccinations.
All that leaves a lot of room for improvement. I think we’ll be able to convince the government that we as hospitalists can have the greatest impact on inpatient quality improvement. The next step is to work with the government to create national standards that we would agree on: beta-blockers after heart attack, counseling for diabetics, smoking cessation, vaccinations for influenza and pneumonia at time of discharge, effective DVT prophylaxis in orthopedic surgery, inhaled steroids for asthmatic patients.
These are all areas where standards can be established and monitored, and where up to now it has clearly been shown that disparities exist. The Society of Hospital Medicine would have the ability to do that, just like the American College of Physicians has been able to establish its own guidelines.
How did your own hospitalist career begin?
I began as a hospitalist before the expression was ever coined. I started working with tertiary orthopedic surgeons back in the 1980s, with several of the lead pelvic acetabular surgeons. One of them in Los Angeles hired my partner and I to manage his patients because he spent all day in the operating room. Those patients were getting more complicated and faced a high risk of DVT and pulmonary emboli.
In 1991, my 2 partners and I started working with a local independent physician association at Good Samaritan Hospital. Shortly thereafter we realized that there were other groups doing similar things in Los Angeles and we formed Cogent in 1993.
How will your experience with Cogent carry over to your work with the national advisory council?
At Cogent, we collect data on different patient groups, feed that data back to our hospitalist groups and look for improvement in three-month intervals. Those are the kind of quality improvement programs in which the government is interested.
And I think I offer an advantage not just because I’m a practicing physician, but because I spend time working at hospitals around the country. I bring to the table a little more than just someone who’s practicing in a single hospital.
Not only am I a long-term hospitalist, but I’m also a mentor for Cogent programs across the country, so I get to deal with issues that other hospitals face in different areas of the country. Each market has its own local or state issues that are different from the others, whether they are liability issues, reimbursement or support issues.
How important has your mentoring role with Cogent been to you?
Very important and very satisfying. Because the hospitalist movement is a new movement, many of its physicians are right out of training. One issue is how we help young physicians step into a job where they suddenly have a huge responsibility for a very sick patient population and they may have difficulties dealing with end-of-life issues. Right now, nobody has a true “hospitalist” program. Most hospitalists come from internal medicine programs.
At the same time, these physicians have to interact and co-manage patients with subspecialists, some of whom are initially reluctant to work with hospitalists. Once these subspecialists see the advantage of having hospitalists readily available to manage their patients, they’re happy to have them aboard.
So a part of mentoring is really to teach them about the value of being a hospitalist and how to work with people “even if they don’t want to work with you