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It could be your boss

Burning out? 
It could be your boss

June 2015
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Published in the June 2015 issue of Today’s Hospitalist

Burning out? 
It could be your boss

BASED ON SURVEY RESPONSES from their own colleagues, Mayo Clinic researchers have identified a strong association between self-reported physician burnout and the leadership behaviors of those physicians’ supervisors.

Results were reported in the April issue of Mayo Clinic Proceedings. More than 2,800 doctors responded to the survey, with 40% reporting at least one symptom of burnout. Respondents also rated their immediate supervisors, who were physicians or scientists, in 12 domains. Every 1-point increase in composite leadership scores was associated with a 3.3% decrease in burnout risk and a 9% increase in reported career satisfaction. Burnout prevalence also correlated with the mean composite leadership rating of each division or department chair.

Too often, the authors wrote, physician leaders are chosen based on clinical expertise or reputation, not leadership capabilities. “Clearly, new strategies are needed,” they concluded, “to identify potential physician leaders and better prepare them for their future leadership role.”

Delays for in-hospital
 stroke patients

COMPARED TO PATIENTS who have community-onset stroke, those who suffer strokes while already in the hospital wait much longer to be treated and have worse outcomes.

Researchers compared more than 900 patients who had strokes while
in regional stroke centers in Ontario to more than 28,800 patients with community-onset strokes. Patients who suffered a stroke in the hospital had lower thrombolysis rates (12% vs. 19%), longer delays between symptom recognition and thrombolysis (2 hours vs. 1.2 hours), and longer waits for neuroimaging (4.5 hours vs. 1.2 hours).

Adjusted mortality rates were similar for both groups of stroke patients. However, patients who suffered in-hospital strokes were less likely to be discharged home (35% vs. 44%). According to the authors, the findings indicate the need to improve and standardize the way that in-hospital strokes are recognized and managed. Results were published online in May by JAMA Neurology.

Discharging low-risk PE patients
 from the ED

HOW WELL DO low-risk PE patients fare if they’re discharged from the ED and have their initial anticoagulation managed as outpatients?

Quite well, according to a research letter posted online in April by JAMA Internal Medicine. In a 2006 clinical trial, outpatient management for low-
risk patients was found to be noninferior to admitting those patients. To test those results, researchers examined 2004-10 data on PE patients from four integrated systems, including Kaiser Permanente in California and Geisinger in Pennsylvania.

The study found that 8.3% of patients were discharged home from the ED, a percentage that rose from 5.6% in 2004 to 11.1% in 2010. About 19% of patients discharged from the ED made another ED visit within 30 days. There were no deaths within seven days among low-risk PE patients discharged home, and 90-day mortality was 0.4%.

“Shifting appropriate patients to outpatient treatment,” authors wrote, “may have benefits in terms of improved quality of life, enhanced physical and social functioning, and reduced costs of medical care.”

Cure for C. diff may involve 
C. diff spores

RESEARCHERS SAY that orally giving patients nontoxigenic C. diff spores may reduce the risk of recurrent episodes of the infection.

A small study published in the May 5 Journal of the American Medical Association found that when adults who had experienced one or more episodes of C. diff were given the spores, 11% suffered a recurrence of the infection “compared to 30% of study subjects given placebo.
Typically, between 25% and 30% of C. diff patients experience recurrence. The study tested several different concentrations of nontoxigenic C. diff spores taken for seven or 14 days vs. placebo for 14 days.

The authors pointed out that nontoxigenic spores are relatively safe because they can’t produce the genes for toxin production and can colonize without causing disease. Serious treatment-related adverse events occurred
in 3% of subjects given the spores, compared to 7% of placebo recipients.

HCAHPS scores: more about
 patients than providers?

WHILE HOSPITALISTS STRUGGLE to improve their patient satisfaction scores, new research indicates that several demographic factors can predict how well (or not) hospitals do in terms of HCAHPS.

The authors analyzed HCAHPS scores across more than 3,900 hospitals. While lower HCAHPS scores seemed to cluster around urban areas, the authors identified four demographic and hospital-related factors that were better predictors of satisfaction scores: the number of hospital beds, the percentage of patients who were non-English speaking, the percentage of patients with bachelor degrees and the percentage who were white.

Results were published online in May by the Journal of Hospital Medicine. “Hospital size and primary language (non’English speaking) most strongly predicted unfavorable HCAHPS scores,” the authors wrote, “whereas education and white ethnicity most strongly predicted favorable HCAHPS scores.”

The authors found that taking those factors into account improved the patient-satisfaction rankings of many safety-net hospitals and academic centers. They recommended that Medicare adjust HCAHPS scores according to those variables before financially penalizing hospitals for poor HCAHPS performance.

New York hospital tests 
hospital at home

NEW YORK’S MOUNT SINAI HOSPITAL is now using a CMS grant of nearly $10 million to launch a “hospital at home” program. That type of program, which is available in only a few self-insured hospital and health care systems including the VA, can lower length of stay and costs for specific diagnoses. However, the care model is not reimbursed by insurers, including Medicare.

The New York Times reports that patients are approached for the program in the ED after an ED physician determines that they need to be admitted. Eligible patients must have stable vital signs, as well as working utilities in their home and room for IV supplies.

The hospital also makes arrangements for backup EMT and 24-hour physician and nurse coverage for patients in the program. One health care system mentioned in the coverage, Presbyterian Healthcare Services in Albuquerque, has offered hospital at home to patients for several years. Only 2.5% of patients enrolled in that program have needed to be admitted to a hospital.

Many PCI patients miss out
on cardiac rehab

A NEW STUDY looking at PCI patients finds that 40% are discharged without a referral for cardiac rehab. That’s despite the fact that cardiac rehab has been associated with lower mortality in PCI patients.

Researchers reviewed more than 1.4 million PCI patients discharged from 1,310 hospitals between 2009 and 2012. While 60% of patients overall were referred for cardiac rehab, more than one-quarter of the hospitals in the analysis referred fewer than 20% of their PCI patients. (Referral rates were better for Medicare patients who had suffered an acute MI: 66%.) Results were published in the May 19 issue of the Journal of the American College of Cardiology.

Larger hospitals and those with higher PCI volumes were more likely to 
refer patients for cardiac rehab, as were private and community hospitals. To boost the number of patients being referred, researchers said that cardiac
rehab referrals should be protocolized and included in discharge order sets.

Nearly half of physicians 
opt out of PQRS

WHILE MEDICARE has given physicians a financial incentive to participate in its reporting program, new data show that nearly half of physicians have decided against participating “and have taken a pay cut in the process.

The CMS gives health care providers a bonus for participating in its Physician-Quality Reporting System. But Healthcare Finance reports that according to government data for the 2013 reporting year, more than 460,000 providers opted out of the program and took a 1.5% pay cut. (The 640,000-plus health care providers who did comply saw a 0.5% boost in their Medicare payments.)

CMS data further show that of the physicians who didn’t participate in the reporting system, 70% treated fewer than 100 Medicare patients a year and 43% treated fewer than 25 Medicare patients.

The lowest number of participating physicians came from psychiatry and general practice. The CMS has said it plans to streamline redundant quality-data mandates to make reporting less of a hassle.

Physician comp is up, 
but so is dissatisfaction

ACCORDING TO the 2015 Medscape Physician Compensation Report, physician compensation for most specialties has made modest gains over the past year. But for some physicians, discontent with overall career satisfaction is also on the rise.

The report, which was released in April and is based on a survey of 19,500 doctors, found that average compensation for internal medicine rose 4% from 2014 to $196,000. Meanwhile, orthopedists ($421,000), cardiologists ($376,000) and GI doctors ($370,000) led the pack in terms of high earners. Family physicians were found to earn $195,000 and pediatricians $189,000.

The report also found that women doctors earn 76 cents for every dollar earned by their male colleagues, although this year’s report finds that the difference in earnings between men and women has decreased since 2011. Among internists, 71% of those surveyed would choose medicine again as a career, but only one in four would choose the same specialty.

McAllen, Texas, and overtreatment

SIX YEARS after he helped make the town of McAllen, Texas, synonymous with health care waste, Atul Gawande, MD, has revisited, and he has new findings to report.

In his original 2009 profile in The New Yorker magazine, Dr. Gawande compared health care costs in McAllen to those of El Paso, another border town. At the time, he found that McAllen had 40% more surgeries, between two and three times as many pacemaker insertions, and fivefold greater per capita spending on home health.

But in the May 11 issue of The New Yorker, Dr. Gawande reports that health care spending in McAllen has dropped nearly $3,000 per patient, largely due to the leadership of local primary care physicians. While a few doctors in the community had to settle kickback allegations, hospital admissions in the community since 2009 have dropped by 10%, while spending on both home health and on ambulance transport has fallen nearly 40%.