Hospital Medicine: Driving the Future of Healthcare

by Dr. Suneel Dhand MD Hospital medicine has become rapidly one of the largest specialties in the United States. As the number of practicing hospital medicine doctors soars above the 44,000 mark and healthcare reform takes hold, the specialty finds itself at the forefront of American medicine. And for good reason. It is a young, dynamic, varied and flexible specialty that can be practiced in a number of different settings. Hospital medicine doctors are no longer just the “stand-in” for the patient’s primary care physician. Hospitals all over the country are increasingly looking to hospitalists to drive quality improvement forward. Having been in practice for over five years, I feel that the best and most committed hospital medicine doctors (that I myself have used as role models) have been the ones who enjoy patient care above all else, and then find a particular niche that they become expert in. I…

Length of Stay Trending Up: What Next? Part II

by Dr. Arun Mohan MD, MBA In my last post, I described substantial geographic variation in length of stay. Although it’s not exactly clear what explains the differences, here are 5 key principles that hospitalists should keep in mind: 1)    Specialization is important.  Research from multiple industries demonstrates that focusing on doing a few things well allows organizations to deliver better outcomes at lower costs. Organizations with narrow focus can build more dedicated facilities, develop more expertise, more effectively standardize care, and learn more quickly. At the hospital level, this may include building centers of excellence or focusing on certain service lines.  At the unit level, this might mean developing units for a given condition or type of patient (e.g. elderly). And at the physician-level, this might mean having hospitalists who are focused on certain conditions. 2)    Workload can effect efficiency.  Studies show that high nurse to patient ratios are…

Length of Stay Trending Up: What Next? – Part I

by Dr. Arun Mohan MD, MBA Do the math and it’s easy to understand why hospital medicine grew so quickly.  Multiply the 14-17% reduction in length of stay achieved by hospitalists by the number of admissions a hospitalist does annually and the value proposition becomes clear.  However hospitals continue to look for opportunities to improve efficiency  as cost pressures change, and they often turn to hospitalists to help them figure it out.  So what can hospitals do? As a matter of background, length of stay is important to hospitals for a combination of clinical and, of course, financial reasons.  Clinically, there is a large body of evidence which demonstrates an association between adverse events and length of stay.  It’s hard to know whether complications lead to long lengths of stay or vice versa, but we all know that bad things can happen in the hospital and that more is not…

CMS, SHM, and the Two-Midnight Rule

We ended the chat and we all felt lost. I am referring to SHM's recent CMS conference call concerning the two-midnight rule.  We wanted to clarify the vague nature in how CMS defines medical necessity—the linchpin of how the rule operates.  (more…)

Readmissions may be more than inpatient stays

"The use of hospital readmissions as a lone metric for post-discharge health care quality may be incomplete without considering the role of the ED." Do you agree? I would probably say yes, providing patients we include in the numerator return to the ED with an issue related to their index trip—be it clinical or ancillary.  We may not like to hear those words, but a return visit, regardless of admission, likely connotes a transition failure. Earlier in the year, JAMA examined HCUP data from three states (CA, FL, and NE) to determine the degree to which ED visits and hospital readmissions contribute to overall use of acute care services within 30 days of discharge from acute care hospitals.  The graph below illustrates the percent of patients returning to the hospital after discharge: (more…)