Operations

Misjudge the Outlier Patient at Your Peril

  A few weeks ago, I wrote about small numbers of patients consuming large and disproportionate shares of health care goods.  The thinking being, if we focus efforts on outliers, hospitals will save money and FTEs by economizing in the right places.  Why waste resources on interventions applied to fifty percent of the hospital population when only ten or twenty will do. While dogma still holds, i.e., a few folks will always consume the greatest slice of the health care pie, we tend to view the statistic at a population-based and not individual level. A recent release from Health Affairs should force us to reconsider our assumptions: For Many Patients Who Use Large Amounts Of Health Care Services, The Need Is Intense Yet Temporary  The study investigators probed to determine whether a cohort of high-needs people who received the label "outlier" remained static over time.  A first of its kind…

Super-Utilizers: Will they be buying or renting beds?

Costs in health care tend to concentrate in the domains of the few (think 80/20 rule).  As it goes for chronically ill community dwellers, the same applies to frequent flyers in the ER.  You may have heard of the term super-utilizers. Those individuals present week after week with innumerable complaints, sometimes pedestrian, sometimes critical--always finding themselves back on the ward for weeks at a time.  As expected, they have weak community support and comorbidities in need of TLC, often requiring services not available in their neighborhoods (mental health and substance abuse counseling come to mind). The local house of worship, community center, or corner bar have limits, and they only offer so much spiritual renewal or sustenance.  We all struggle to find a balance for these folks.  We see them a lot.  And thus, the ER becomes their second home. (more…)

Readmits and ER Docs: Looks Like They Need Their Own Special Penalty Box

We have conditioned ourselves to think of readmits in three domains: care transitions (us), patient factors, and community determinants.  Guess what?  I will give you number four.  ER docs.  A new study in JHM looked at the role ERs, and ER physicians play in fee for service Medicare readmissions. The investigators looked at four years of data from Texas hospitals (2008-11), encompassing three million person encounters.  They examined patterns of admission after visits to the ED--readmitted on the same day and up to thirty days post initial presentation.  They made all the usual adjustments. (more…)

Antibiotic Stewardship and Hospitalists: The Bedside Is the Front Line

by Eric Howell, MD, SFHM “Tell me what you know about antibiotics.” That’s the discussion I start with hospitalized patients all the time, right after they ask me to prescribe antibiotics for their simple cough, or other viral-like illness. And, from their perspective, asking for antibiotics makes sense. After all, antibiotics have been the physician’s knee-jerk reaction to a number of patient symptoms for decades, especially for a cough or upper respiratory infection. And we have inadvertently trained our patients that there is an easy solution to almost any common medical problem. But patients often answer my question with something like “not much” and a little surprise that I haven’t already started ordering the prescription. That’s when I talk about the potential harms of antibiotics. And that’s also when their eyebrows go up. I start with the easy harms, like that many antibiotics can cause diarrhea, a symptom nobody wants…

Engaging Hospitalists: What Makes You Tick?

by Jerome Siy, MD, SFHM, CHIE It would be easy to deliver on the triple aim if all hospitalists had to do was run a checklist.  But, it’s pretty obvious that we need more than a checklist to be successful.  How many of us are graduated in the top 10% of our class, but can’t get a score above 70% on our HCAPS scores?  A checklist is something we should be familiar with.  It’s how we got through medical school, and how we passed our boards.  Are we passing in our hospital medicine practice? Don’t get me wrong.  The checklist helps. A gentle reminder to foam in and foam out, a cue to sit down before I begin a conversation with a vulnerable patient, or a nudge to lend a hand at the next ED to inpatient lean project are all important ways we can improve upon our hospitalist mission.  If…
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