Effectiveness/Efficiency

Admitted to Hospital #1, Readmitted to #2. What happens to mortality?

  Unless I have a pressing inpatient problem in need of a subspecialty consult, I defer to the outpatient setting.  This goes double if the patient’s PMD practices elsewhere.   You can guarantee any benefit of "urgent" consultation will be outweighed by the harms of siloed care and information drops when we set the patient adrift in the community.  Better the patient sees a colleague of their regular doctor.  At least the discharging doc will know treatment inertia moved in the right direction, lowering the risk of an adverse event. (more…)

Hospitalists “Seeing Wisely”: A High Value Proposition

I remember being a third year medical student and reading Bob Wachter’s piece in the New England Journal of Medicine that made the term “hospitalist” mainstream. I was intrigued. I matched at the University of Chicago, which was one of the few programs in the country at the time that had a hospitalist program.  When I rotated on the academic hospitalist service as an intern, I distinctly remember being taught about the possibility of influenza in a febrile older diabetic patient who had been started on broad-spectrum intravenous antibiotics. I immediately ran to fetch a viral swab and sent it to the lab. Bingo…Later that afternoon, the patient had been diagnosed with influenza A. What’s even more exciting is that we could stop the broad-spectrum intravenous antibiotics, which were both unnecessary and potentially harmful. Moreover, I could remove the “culture if spikes” recommendation on his sign-out, since the daily cultures…

2013: Did we pay more for inpatient care, or did we use more?

  The Health Care Cost Institute is not just another consulting firm or think tank.  They are a a non-partisan, non-profit clearinghouse for all things health care payment.  They obtain commercial and government data and generate reports on health spending direction. Their 2014 release analyzing 2013 commercial trends (think age 18-64 yo)  came out last week. The report has oodles of data and fun graphics covering many domains--but since we live on the inpatient side, you might also want to  take a look at the hospital end of things.  After all, hospital bottom lines live and die by employer sponsored insurance and the rates they pay (or hospitals accept). The verdict?  Inpatient use down, with care intensity and prices up (average price of a stay equals ~$18K). Have a look (page 7 of the report): (more…)

Hospitalists Caught between a RAC and a Hard Place

by Melinda J. Johnson, MD, FHM, FACP The observation status problem has continued to grow both larger and worse. My hospitalist colleagues and I are caring for patients in hospital beds in the exact same way as other patients in the hospital, but we are told that we must give them the designation called observation status.  CMS recognizes observation status as outpatient care, like seeing a patient in a walk-in clinic. We don't "decide" to make a patient observation status.  When a patient is admitted to us, someone else (who is usually not a physician) has already decided the patient is observation status.  Hypothetically, we can write an order to change that status, but we are being watched very closely, and our decision to change the status will be challenged in (almost) a heartbeat.  We are being watched by people paid by our hospitals to make sure that no patient…

Do hospital-based docs get sued more? Part II

  I left off last week’s post with a tease.  If you recall, I made note of the frequent mentions med mal gets in the lay and professional press, as well as the outsized influence the threat of getting sued has on physician psyches. Physician surveys, albeit with their biases, can tell us how we feel about medical torts.  However, as a field, from those same surveys, we discern little of our actual risk. Relative to our outpatient or subspecialty colleagues, the system has saddled us with a distinct data disadvantage. We have no unique identifier or tracking ability, so assessing suitable premiums and sussing out trends within our specialty--and where we fall short (or not), make corrective actions difficult. It would be nice to have a study like this, for example, as the day may come when malpractice carriers disaggregate inpatient from outpatient claims.  Our discipline has weaknesses for sure, like…
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