Published in the February 2016 issue of Today’s Hospitalist
Physician burnout: It’s getting worse
IN 2012, a study published in what was then the Archives of Internal Medicine by researchers from the Mayo Clinic found that 45.8% of surveyed physicians reported at least one symptom of burnout. The same researchers surveyed doctors again in 2014, and they now report that physician burnout is getting worse.
The latest survey found that 54.4% of doctors had experienced at least one burnout symptom, a 19.5% increase over the 2012 results. Thirty-nine percent screened positive for depression, the same percentage as in the previous research, but only 41% of surveyed physicians in the current study believed their work schedule left them enough time for their personal and/or family life. In the 2012 study, that figure was 48%. Results were published in the December issue of Mayo Clinic Proceedings.
Among the general population, 25% in both studies reported at least one burnout symptom. The authors noted that the gap between physician burnout and that experienced by the general population is getting wider.
Hospitalists unionize in standoff with administration
A DISPUTE between a hospitalist group and its hospital administration has led the physicians to join a union, although they have yet to sign a contract with the hospital.
The New York Times last month profiled the hospitalist group at a hospital in Oregon, where the physicians pushed back after being told in 2014 that their employed group would be put out for bids from management companies. The doctors say that because they expected they would have to see many more patients if their group was outsourced, they affiliated with the American Federation of Teachers, which already represented nurses at the hospital.
But a year later, the doctors still don’t have a contract and have not been able to agree with administration on several issues. Contested items include the number of shifts the physicians need to work per year and how much “skin in the game”—in terms of taking some risk for the hospital’s financial performance—they may be required to take.
The end of meaningful use?
IN REMARKS made last month at a health care conference, the acting head of the Centers for Medicare and Medicaid Services (CMS) announced that as of this year, the meaningful use program will be “effectively over and replaced with something better.” Details of what will replace meaningful use, he went on to say, should be released in a few months.
In his remarks, the administrator cited physician frustration as a major reason why the meaningful-use program will sunset. He also said that the agency is looking for ways to attract start-ups and technology entrepreneurs to health care information technology, with an eye to “open” application programming interfaces, which determine how one application interacts with another. The administrator also noted that the agency is “deadly serious about interoperability,” according to HealthLeaders Media coverage.
The reaction from health care chief information officers (CIOs) largely supported ending the program. CIOs noted that meaningful use is not adding value and is getting in the way of health care systems implementing other IT-related innovations.
Non-STEMI: immediate vs. delayed angiography
HOW CRITICAL IS IT to get immediate angiography for patients with non-ST-segment myocardial infarction? Results published in the January issue of JACC Cardiovascular Interventions indicate that immediate angiography reduced patients’ chance of both recurring MI and death at 30 days by nearly two-thirds (62%).
The trial randomized more than 320 non-STEMI patients to either angiography in less than two hours after randomization or to a delayed intervention group that received angiography within between two and 72 hours. The median time from randomization to angiography for the two groups was 1.4 hours and 61 hours, respectively.
Among patients in the immediate-intervention group, the rate of death and recurrent MI at 30 days was 4.3% vs. 13% for the delayed group, a difference that persisted at one year (6.8% vs. 18.8%). “The observed results,” the authors wrote, “were mainly attributable to the occurrence of new MI in the pre-catheterization period.”
All patients received dual-antiplatelet therapy. In the immediate intervention group, patients were randomized five hours after symptom onset vs. 6.5 hours for those in the delayed-treatment group.
Does discharge before noon work?
HOSPITALS ARE IMPLEMENTING discharge before noon incentives, designed to improve patient flow. But according to one new study, a discharge-before-noon policy—at least in one academic medical center— was associated with longer lengths of stay.
In the study, researchers from the University of California, San Francisco, looked at nearly three years of data and found that 17% of discharges took place before noon. However, those discharges had longer lengths of stay, an association that was particularly pronounced among patients admitted through the ED.
The authors stressed that the results provide no evidence that “discharges were delayed to achieve discharge before noon.” But they do conclude that length of stay may be a flawed metric to gauge the success of discharge-before-noon programs. They also noted that other measures (such as the impact on ED wait times) might be more effective. Results were posted online in December by the Journal of Hospital Medicine.
Updated VTE-treatment recommendations
THE AMERICAN COLLEGE OF CHEST PHYSICIANS last month released more than 50 updated recommendations to treat VTE. The new guidelines were published in the January issue of Chest.
Among the new recommendations: Physicians should prescribe a novel oral anticoagulant, not warfarin, for long-term VTE therapy in patients who don’t have cancer. For VTE patients with cancer, the guidelines recommend low-molecular-weight heparin over either warfarin or novel oral anticoagulants.
Other recommendations include prescribing aspirin when stopping anticoagulation in patients with unprovoked proximal DVT or PE to reduce the risk of recurrence, having patients with low-risk PEs be treated at home or considered for early discharge, and not having patients receive an IVC filter for VTE treated with anticoagulants. The revised guidelines also recommend against using compression stockings to prevent post-thrombotic syndrome in patients with acute leg DVT.
Guideline authors also noted that among the new recommendations, “none was based on high quality evidence, highlighting the need for further research.”
How often should you monitor INRs?
IN A NEW STUDY, researchers argue that hospitals should be monitoring INRs daily for patients receiving warfarin to better recognize rapidly-rising INRs and head off warfarin-associated adverse events.
The authors analyzed 2009-13 Medicare data on randomly selected hospitals and on patients receiving warfarin who were hospitalized for pneumonia, acute cardiac disease or surgery. Among more than 8,500 patients who received warfarin for three or more days, more than 18% did not have their INR measured on two or more of those days.
Within that subset, cardiac and surgery patients had higher odds of a warfarin-related event, while cardiac and pneumonia patients had higher odds of an INR of 6.0 or higher.
“Because our results suggest that lapses in INR measurement lead to overanticoagulation and warfarin-related adverse events,” the authors wrote, “it may be appropriate to measure INRs daily in most hospitalized patients receiving warfarin.” Results were posted online in December by the Journal of Hospital Medicine.
Short-term antibiotics effective in select UTI patients
A RETROSPECTIVE STUDY has found that prescribing short courses of antibiotics for select patients with gram-negative bacteremia can be just as effective as longer-term treatment.
Researchers found that when patients’ temperatures fell below 100.4F within 72 hours of initiating therapy, they did well with short-term antibiotics of seven days or less. The research compared patients treated for seven days or fewer, eight to 14 days, or more than 14 days. Study results were posted online in December by Infectious Diseases in Clinical Practice.
Persisting fever predicted patients’ clinical response, and those who maintained a fever for more than 72 hours after treatment began had a significantly poorer response to short-term therapy. The most common source of the bacteremia was the urinary tract (53%) and indwelling catheters (14%).
Among patient groups, overall clinical response rates were 79% for those taking antibiotics no longer than seven days, 89% for eight through 14 days of therapy, and 81% for more than 14 days. Researchers noted that the results wouldn’t apply to multidrug-resistant gram-negative organisms.
IV antibiotics at home cut costs, readmissions
A NEW STUDY that looks at the impact of teaching uninsured patients how to self-administer long-term IV antibiotics at home indicates that these patients have better outcomes than individuals given IV antibiotics by home health workers.
The four-year study compared nearly 1,000 uninsured patients who were taught to administer their own IVs at home to more than 200 patients who received IV antibiotics through home health services. Self-administered patients had 47% fewer readmissions at 30 days, while the mortality rates between the two groups were the same.
The authors point out that while insured patients can access home health workers, uninsured patients who need long-term IV antibiotics might otherwise have to spend weeks in the hospital. Among the patients in the study, self-administering IV antibiotics saved a median of 26 days of inpatient perfusion per patient, avoiding more than 27,000 inpatient days. Study results were posted in December by PLOS Medicine.
“Back to the future” care for high-risk older patients?
A VIEWPOINT published in the Jan. 5, 2016, Journal of the American Medical Association argues that current delivery systems aren’t meeting the needs of older patients with multiple comorbidities. According to the authors, two emerging models may provide the continuity such patients need.
One potential approach is the comprehensive care physician model being piloted at the University of Chicago. In that program, hospitalists are given a panel of 200 high-risk Medicare patients and round on those who are admitted, while also providing outpatient care.
The second model highlighted is being used by CareMore, an HMO in southern California. Hospitalists in that model act as extensivists, each having a panel of 100 high-risk patients and following those patients in the hospital as well as in outpatient and post-acute settings.
Early CareMore data indicate that using extensivists—instead of dividing high-risk patients’ care between acute-care hospitalists and outpatient physicians—delivers shorter lengths of stay and fewer readmissions. The comprehensive care model is now part of a randomized trial, with results due this year.
Merging hospitals, rising costs?
MOST OF THE CONVENTIONAL WISDOM on how health care costs vary across different markets comes from an analysis of Medicare data. But Medicare covers only 16% of Americans, according to a new report, and health care costs in different markets for private insurance can be far higher than for Medicare.
That’s particularly true in areas where hospital consolidation has tamped down competition. The report, which was published in December and incorporates data from a huge database of employer-sponsored insurance, finds that in markets with monopoly hospitals, prices for private insurers are 15% higher than in markets that have four or more hospitals.
The report was prepared by a group of economists for the Health Care Pricing Project. According to New York Times coverage of the report, “Larger, integrated hospital systems can often spend less money in Medicare, but those systems also tend to set higher prices in private markets, because they face relatively little local competition.”
Drug, opioid overdoses are on the rise
THE NUMBER OF OVERDOSE DEATHS in 2014 was the highest on record, exceeding 47,000. That’s according to the CDC’s Morbidity and Mortality Weekly Report issued Jan. 1.
That figure represents a 6.5% increase over the number of overdose deaths in 2013 and a 137% increase since 2000. The five states with the highest rate of overdose deaths in 2014 were West Virginia, New Mexico, New Hampshire, Kentucky and Ohio.
Fourteen other states had a statistically significant increase in the number of drug-overdose deaths between 2013 and 2014. By contrast, the number of drug-overdose deaths associated with methadone stayed the same both years.
The data, the CDC wrote, point to “two distinct but interrelated trends: a 15-year increase in overdose deaths involving prescription opioid pain relievers and a recent surge in illicit opioid overdose deaths, driven largely by heroin.” The report also noted that oxycodone and hydrocodone “continue to be involved in more overdose deaths than any other opioid type.”
The case for open ICU visitation
DOING AWAY WITH even minimal restrictions on visiting critically ill patients may improve family satisfaction within the ICU. That’s according to a new study that surveyed family members in one tertiary center both before and after an open-ICU visitation policy was put in place.
Before the new open-visitation policy, the 24-bed ICU was closed to visitors for about three hours a day during nursing handoff reports. The study, which appeared in the January issue of the American Journal of Critical Care, noted that many ICUs continue to restrict visitation.
Since the new policy took effect, visitors are now welcome at all times, with limits imposed only by patient preference or clinical status. Researchers found that unrestricted visiting hours significantly boosted family members’ satisfaction with visitation as well as nurses’ perception of family satisfaction. The level of nursing satisfaction remained unchanged after the new visitation policy was put in place.
To fight superbugs, start with your food service
AMID GROWING CONCERN that the antibiotics used to raise meat are driving up resistance rates, more hospitals are beginning to serve meat raised without antibiotics.
An article posted last month by NPR notes that a group of more than 400 hospitals is working toward having 20% of the meat they serve be antibiotic-free. Price is a concern—chicken raised without antibiotics is 30% more expensive—while availability has also been a problem.
Increasingly, however, meat suppliers are meeting demand, NPR reports, giving hospitals more flexibility. Last year, several major restaurant and retail chains (including McDonalds, Subway and Costco) also committed to selling more antibiotic-free meat.
The article points out that 2 million Americans are infected by antibiotic-resistant bacteria every year, producing an annual toll of 23,000 superbug-related deaths.