The Year in Hospital Medicine: 2015 Clinical and Practice Changers

Larry Beresford

Disclosures

December 23, 2015

Hospital Medicine: A Year of Transformation

The field of hospital medicine was dominated by transformation in 2015, much of which was driven by US healthcare reform and the Affordable Care Act. Much of the movement was toward consolidation, value-based purchasing, population- and risk-based health coverage, and the accountable care organizations (ACOs) and other integrated systems that are emerging to make those payment models succeed.

The anticipated big jump away from fee-for-service toward risk-based healthcare coverage hasn't happened yet for most hospitalists, but the major players are scrambling to get ready for it. For hospitalists, their role in managing the health of populations cost-effectively is expected to grow, creating new assignments, expectations, and accountabilities.

"The big trends in hospital medicine in 2015 involved the accelerating pace of healthcare reform," said Bradley Flansbaum, DO, MPH, MHM, a hospitalist at Lenox Hill Hospital in New York City, and blogger at The Hospital Leader. "There is a lot of uncertainty about how hospital and health system integration will affect inpatient practices. We may not know for another 5 or 10 years the impact of changes going on now, but one day we'll look back and say: This was a time of great change."

Many of the things that save money under risk-based care—for example, avoiding infections, blood clots, and readmissions—are influenced by hospitalists, said Laurence Wellikson, MD, SFHM, chief executive officer of the Society of Hospital Medicine (SHM). "Hospital medicine is well-positioned to be a key asset in driving and demonstrating value."

A growing proportion of payment from Medicare and other insurers will include a value-based adjustment, while another big trend is bundling of payment for all services for a discrete procedure. In November, the federal Centers for Disease Control and Prevention published a final rule, effective April 1, 2016, for the comprehensive care for joint replacement model—a mandatory bundled payment for all hip and knee replacement care from surgery until 90 days posthospitalization in 67 metropolitan service areas. This bundled payment builds on recent Centers for Medicare & Medicaid Services experience with bundled payment demonstrations and seeks to incentivize Medicare providers and suppliers to work together to improve quality and reduce costs.

How will hospitals be asked to oversee and shepherd bundled episodes of care and the dividing of resources? Dr Flansbaum wondered. "This will be easier with elective surgical procedures like a joint replacement, which are relatively predictable, rather than with medical diagnoses, where we will need to better define an episode of care."

The Big Get Bigger

A simultaneous trend in hospital medicine is toward consolidation, explained Ron Greeno, MD, MHM, FCCP, chief strategy officer for IPC Healthcare. Dr Greeno, a founding member of SHM and current chair of its Public Policy Committee, said his own experience reflects the larger trend. "I was with Cogent for 20 years until its sale. Now I've worked for four organizations in less than 12 months." Many of the recent mergers are across medical specialties or between hospitals and physician groups, leading to more employment of doctors by hospitals and health systems, Dr Greeno said.

A recent Daily Briefing article[1] from the Advisory Board Company notes that employment in the healthcare sector is booming, with 500,000 jobs added in the past year; and 1 in 9 US jobs is now in healthcare. Hospitals have been the biggest driver of this growth. Along with this growth in jobs comes an expanded scope of practice in hospital medicine, with growing roles in perioperative care, palliative care, critical care, postdischarge care and postacute care.

One thing is clear, Dr Greeno added. "Hospitalists are critical to anybody's ability to manage population health. But there will be more pressure on their accountability. Stakes will be high—and that's true for all hospitalists, no matter who they work for. There will be tremendous demand for physician leadership and for people with our backgrounds to be leaders for these organizations. They'll need clinical people at the top of organizations in order to get the delivery system changes demanded by risk-based payment right," he said.

"We'll be a critical piece of health systems' ability to take risks, and that's a good place to be. It will be a golden opportunity for hospitalists to really demonstrate our value," Dr Greeno added. "Incentives will change from payment based on productivity to payment based on performance. We'll be paid to help the organization—not our HM practice—succeed. And there are lot more changes coming in 2016."

One drawback, said Dr Wellikson, is that medical school training and preparation are not keeping pace with the changes. "Every hospitalist today should have a portable ultrasound machine in his or her pocket. Doctors should come out of training very familiar with how to use their cell phones on the job. I can't say that all hospitalists are now ready for the big leagues—but I can't think of another specialty better positioned for what's coming. Hospitalists are rooting for it to hurry up and arrive."

Key Clinical Research From 2015

Key research studies published in the previous 12 months and relevant to hospitalist practice were presented by Bradley Sharpe, MD, hospitalist at the University of California, San Francisco (UCSF), in a "Year in Review" presentation for the UCSF Management of the Hospitalized Patient conference in San Francisco in October. The following list was reviewed by Dr Sharpe for Medscape.

Community-Acquired Pneumonia

Antibiotic Treatment Strategies for Community-acquired Pneumonia in Adults

Postma DF, van Werkhoven CH, van Elden LJ, et al; CAP-START Study Group
N Engl J Med. 2015;372:1312-1323

When patients with clinically suspected community-acquired pneumonia (CAP) are admitted to the hospital, what should be the recommended empirical antibiotic therapy while waiting for cultures to come back? What about treating atypical bacteria?

Researchers in The Netherlands compared strategies for empirical treatment with beta-lactam monotherapy and combination therapies, finding that monotherapy was not inferior to the other approaches with regard to 90-day mortality. The study also raises important questions about the use of atypical antibiotics, Dr Sharpe said.

"My take is that these results are not yet generalizable to the United States. Are our bugs different? They might be. This isn't a practice changer yet, but more research will be done in the next few years," he added.

Steroids for Pneumonia

Corticosteroid Therapy for Patients Hospitalized With Community-Acquired Pneumonia: A Systematic Review and Meta-analysis

Siemieniuk RA, Meade MO, Alonso-Coello P, et al
Ann Intern Med. 2015;163:519-528

Dr Sharpe cited this meta-analysis of the adjunctive use of systemic corticosteroid therapy for hospitalized patients with CAP, finding that it may be associated with "possible reductions in all-cause mortality," along with a decrease in the need for mechanical ventilation and shorter length of hospital stay.

"The reason to treat CAP with steroids is that it decreases inflammation," Dr Sharpe observed. "This study showed clinical benefit and no clear harm. But is this enough to completely change what we do? I'm not convinced yet. This study is strong but we don't know enough details yet to change our practice. For which patients? What dose, and for how long?"

Treatment of Bleeding Ulcers

Intermittent vs Continuous Proton-Pump Inhibitor Therapy for High-risk Bleeding Ulcers: A Systematic Review and Meta-analysis

Sachar H, Vaidya K, Laine L
JAMA Intern Med. 2014;174:1755-1762

For patients with high-risk bleeding ulcers, researchers compared current, guideline-recommended continuous infusion of proton-pump inhibitors (PPIs) after endoscopy with an intermittent, twice-a-day PPI therapy, finding that intermittent PPI therapy is comparable to the current guideline-recommended regimen.

"Many doctors around the country were already doing the twice-a-day oral approach," Dr Sharpe said. "This study has important dose, cost, and resource implications. Based on the study, our group at UCSF has changed its practice."

Shorter Course of Antibiotics

Trial of Short-Course Antimicrobial Therapy for Intraabdominal Infection

Sawyer RG, Claridge JA, Nathens AB, et al
N Engl J Med. 2015;372:1996-2005

A randomized controlled trial compared a fixed course (of 4 days) for antimicrobial therapy for intra-abdominal infection with usual care (ie, receiving antibiotics until 2 days after resolution of fever or other symptoms, which might take up to 10 days). In this study, median duration of therapy was 4 days for the experimental group and 8 days for the control. No significant differences in primary or secondary outcomes were found between the two groups.

"This study is a practice changer," Dr Sharp said. "We do see patients with complicated intra-abdominal infections, and before this well-designed study, practice variation was wide. It shows that 4 days of antibiotics after source control is enough, unless the patient is not better after 4 days. Clearly, these patients did not do worse with a much shorter antibiotic course—which is also a way to reduce their risk for contracting Clostridium difficile."

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