Trends come in threes
All things come in threes, or so they say.
In my time in practice, I have cared for many undocumented adults. Usually Latino, young, and male, their issues reduce into two categories: injuries related to work (construction and food service) and uncontrolled flares of chronic conditions (diabetes and asthma). Occasionally, I also care for desperate folks in need of dialysis, transplants, or continued mechanical ventilation. Difficulty understates the latter category.
An average hospital is…..?
A quick post on something we do not think about often.
We look at the world through our own professional lens. If you toil at a big urban hospital, your sphere of interest encompasses GME, training, research, and safety net care. Conversely, if you work at a small, rural hospital, you concentrate on ER and ward coverage, adequacy of services, and connectivity to neighboring facilities and unavailable technology.
An Important Change to Post-Acute Planning That Affects Hospital Providers (Us)
An important proposed settlement between CMS and the Center for Medicare Advocacy last week will alter our approach to post-acute care.
More Transitions Studies, More Mediocrity
A number of studies were released this month that deserve mention—all related to care transitions. A recurrent theme we are adjusting to, the findings ranged from disappointing to mediocre. Two appeared in Annals of Internal Medicine (with an associated commentary), and one, a brief from Health Affairs, gives pause to policy makers and administrators as they embrace technology and human capital to avoid readmissions and improve patient satisfaction (see the links–typical ).
Aside from hospital measurement, and inadequate data adjustments to render truth —an issue I have addressed numerous times on this blog—I find only limited evidence supporting individual, not clustered interventions in improving transitional care. For example, medication reconciliation works, but when used simultaneously with a pharmacist, transitions coach, in a VA hospital in an urban setting, how does that help us? On a limited budget, how does a hospital choose interventions pragmatically, and what is their interrelatedness. Mainly, can you use one intervention without the other, a challenge even our own BOOST presents.
I do not have an answer, and based on the literature, do not hold your breath.
The first study in AIM is a systematic review titled, Transitional Care After Hospitalization for Acute Stroke or Myocardial Infarction:
Conclusion: Available evidence shows that hospital-initiated transitional care can improve some outcomes in adults hospitalized for stroke or MI. Finding additional transitional care interventions that improve functional outcomes and prevent rehospitalizations and adverse events is a high priority for the growing population of patients who have an MI or a stroke.
The second study in AIM is also a systematic review (and similar to a Oct ’11 release): Improving Patient Handovers From Hospital to Primary Care:
Conclusion: Many interventions have positive effects on patient care. However, given the complexity of interventions and outcome measures, the literature does not permit firm conclusions about which interventions have these effects.
Finally, Health Affairs released a terrific brief on Improving Care Transitions. Succinct and well done, I recommend it for newbies getting up to speed on the subject.
Now go read!
Do You Know The Nursing Specialties?
This recent article from the NYT (on the need for RN’s to obtain bachelor degrees) got me thinking (again) about all the conversation these days regarding scope of practice and what specialty paths nurses can pursue.
Observation Units: Its About the Patients
Recall your last credit card statement. On it is the hotel charge from your last out of town CME excursion. Below the total charge you were expecting, is a separate line item for a $75 “recreational fee.” You call the hotel, and they inform you that because of your use of the gym and pool—accessed with your room key—they levied the fee. No signs, alerts, or postings to denote policy, and you innocently expected inclusive use of the facilities as a price of your visit.
Here is a twist of irony.
Physicians, and rightfully so, are called hypocrites, when on one hand they decry the payment system for inadequate reimbursements (and threaten patient access), while on the other, abhor solutions to remedy the same problem. Adoption of midlevels (NP’s and PA’s), which obviously are less costly, but also crowd out physicians and encroach on sacred turf is a prime example:
New JHM Paper: The Everything You Wanted To Know Edition
Yes, another citation. This one is worth your time though.
There simply is too much here to summarize, and besides, by the time I was done , you would have finished the paper anyway.
Green House-ist? Yes, Green House-ist!
The August study in The Annals of Internal Medicine assessing global costs of hospitalist care both inside the hospital, and subsequent to discharge initiated reflections within our ranks. It was also prominent in the lay press (“Are hospital-based doctors fueling health spending?“).
Doctor Nurse or Doctor Doctor
In New York State, the issue of scope of practice is at the fore. Mainly, what activities can non-physicians (NP’s) engage in, with or without physician supervision? It is a heated subject here where I reside, but not the one I will address below.