Wednesday, April 23, 2014

SHM 2014: the prevailing winds of hospital medicine

This is my second post about the 2014 Society of Hospital Medicine national meeting in Las Vegas. I decided to use Bob Wachter's blog form April 14 as a starting point. I intended to review his entire post on Saturday but got stuck on the first paragraph. But Bob had a good deal more to say. My reactions were all over the map (agree, disagree, hope you're wrong, I told you so) so let's dive right in.

One of the big topics for discussion in the plenary sessions was the impact of the ever changing regulatory environment on hospital medicine. Bob predicts a major trend toward closure of hospitals in just the next few years as if it's something new. But we've seen this before, haven't we? In fact it's been going on ever since Medicare enacted the Prospective Payment System (DRGs) in 1983.

Consider this paper for example. According to the report many hospitals closed in the 1980s due at least in part to the advent of Medicare's Prospective Payment System:

Throughout the 1980s a tremendous number of rural hospitals closed their doors nationwide due to the impact of rural outmigration, shifting demographics and changes in Medicare payment methodologies.

This section of the report elaborates on the impact of DRGs:

Early on, Medicare and many other third party insurers simply paid what the hospital charged for the care received by the beneficiary. Then, in 1982, as a result of the TaxEquity and Fiscal Responsibility Act8 (TEFRA), Medicare started transitioning over to a new reimbursement methodology called the prospective payment system in an effort tocontrol costs. For inpatient services, Medicare would pay a set amount per diagnosis related group (DRG)9
As McGuire et al. (1993) point out, PPS was designed to reward efficiency. If a hospital could find a way to keep its costs below the rate of payment, the difference could be considered a profit. This concept was problematic for many rural hospitals because costs were usually well above these generally determined reimbursement rates. Fluctuations in the cost of providing care were not taken nto account by Medicare and were skewed toward urban providers. Medicare has saved a lot of money over the years but cost rural America a lot of hospitals as well.

A lot of hospitals did close and those that stayed open shifted inpatient beds to other lines of service. Things only got worse through the years as Medicare tightened its noose and private payers adopted the DRG model. We've been on a trajectory of more and more regulatory baggage ever since but it has been smooth. Obamacare means we'll progress along that continuum. It'll be disruptive but not nearly so much as with DRGs unless I miss my guess.

So what, says Bob, does this mean for hospitalists? Why, value! It's been Bob's mantra for years and it goes something like this: the hospitalist model has proven its value (in terms of resource utilization and outcomes) up to now and will have to work even harder to do so in order to thrive as a specialty in the future. I'm sure Bob would have some nuance to add but it's certainly the group think at SHM these days. So we have two ideas in need of critical examination.

First, have we proven our value by any measure? Bob says in his post:

The point here is that, just as hospitalists took over the world of hospital care because they demonstrated that they could provide high-quality care at a lower cost, the increasing financial pressures that hospitals are under will create, in turn, pressures on hospitalist programs to achieve quality, safety, patient satisfaction, and efficiency outcomes at the lowest possible cost to the hospital...
The reason the hospitalist field thrived was that it demonstrated that it delivered better value than traditional models.

Well, that's debatable. As I've blogged time and time again the evidence is mixed. I'll not rehash it all here other than to say that one of the best and largest studies ever to address this question showed no benefit of the model. It can be accessed on page 25 of this issue of The Hospitalist but as far as I know has never been published in a Medline indexed journal. So it's been tossed down the memory hole and has contributed to the publication bias that has plagued this literature ever since. I'm happy to listen to arguments on both sides of the question but you can't take it for granted that the hospitalist model has been proven superior to the traditional model. There's just not a clean evidential case to be made.

In terms of demonstrating our value to secure our future, how about just showing up? Outside of our ranks fewer and fewer doctors are willing to take care of hospitalized patients. There’s no reason to think the increasingly harsh regulatory environment will do anything other than drive the rest of the non-hospitalists out of the building.

Consider emergency medicine and its parallels with our specialty. Though under the same economic and regulatory pressures as we are you don’t find them crowing about their value. Their emphasis is clinical which is why I have so many of EM blogs linked here. They’re thriving quite well with that singular focus. There are lessons we can learn from them.

Saturday, April 19, 2014

SHM 2014: visceral reactions

The 2014 national meeting of the Society of Hospital Medicine was held March 25-27. I've been busy since I got back and am just now getting around to “blogging the conference.” This, I hope, will be but one of a series of posts about the meeting.

Bob Wachter shared some of his thoughts the other day. I thought I'd read his post before starting. Bob can be a little provocative and sure enough his comments got me going.  In Bob's opening I was struck by this:

As Win Whitcomb, who co-founded SHM, wrote to me, the meeting is “a mix of love, deep sense of purpose, community, mission, changing-the world, and just plain sizzle,” and I completely agree.

Unfortunately that quote matches my own observations concerning what the sizzle was about: community, mission, changing the world. But what happened to the clinical care of the individual hospitalized patient? Sadly, there didn't seem to be a lot of energy focused on that aspect. Sure there were clinical break out sessions (yes, they were good and will be the subject of future posts here) but they seemed to be relegated to a lesser status. It was as if the clinical content was incidental. That seems to be the general direction of the organization.

It wasn't always that way. It was different when I first attended our national meeting about a decade ago (when we were known as NAIP, the National Association of Inpatient Physicians). The buzz as I remember it back then was about things like sepsis, pneumonia, mystery cases and complex cases of thromboembolic disease. The focus was clinical.

Not so much nowadays. In the plenary sessions I got the feeling this was a meeting for hospital administrators, policy makers and public health professionals rather than doctors. The “patients” they talked about were the hospitals, the health care systems and the larger communities, not the individuals populating the hospital wards.

We need the leaders of our field to go back to promoting hospitalists as clinicians. Unfortunately I didn't see that happening at SHM 14.

EM talks from Vanderbilt

By Corey Slovis and others.

Tuesday, April 15, 2014

The Z-drugs: zolpidem, zopiclone, and zaleplon

From a recent review:

The Z-drugs zolpidem, zopiclone, and zaleplon were hailed as the innovative hypnotics of the new millennium, an improvement to traditional benzodiazepines in the management of insomnia. Increasing reports of adverse events including bizarre behavior and falls in the elderly have prompted calls for caution and regulation..Z-drugs exert their effects through increased γ-aminobutyric acid (GABA) transmission at the same GABA-type A receptor as benzodiazepines..Poisoning with Z-drugs involves predominantly sedation and coma with supportive management being adequate in the majority. Flumazenil has been reported to reverse sedation from all three Z-drugs. Deaths from Z-drugs are rare and more likely to occur with polydrug overdose.