Clinical question: Does darbepoetin alfa use in patients with diabetes and chronic kidney disease (CKD) who do not require dialysis decrease the risk of death and cardiovascular or renal events?

Background: Anemia is a risk factor for cardiovascular and renal outcomes. The use of erythropoiesis-stimulating agents (ESAs) to increase hemoglobin reduces the need for transfusions and moderately improves quality of life. A placebo-controlled trial to determine if correction of anemia with ESAs improves clinical outcomes has not been conducted.

Study design: Randomized, double-blind, placebo-controlled trial.

Setting: 623 sites in 24 countries.

Synopsis: The study team randomized 4,038 patients to receive either dose-adjusted darbepoetin alfa (goal hemoglobin of 13) or placebo, with rescue doses of darbepoetin for hemoglobin below 9g/dL. The primary endpoints were a composite outcome of death, a cardiovascular event and death, or end-stage renal disease.

The median hemoglobin achieved in the darbepoetin and placebo groups were 12.5g/dL and 10.6g/dL, respectively. The primary cardiovascular endpoint occurred in 31.4% of patients receiving darbepoetin and 29.7% of patients receiving placebo (HR 1.05; 95% CI, 0.94-1.17). The primary renal endpoint occurred in 32.4% of patients assigned to darbepoetin and 30.5% of patients assigned to placebo (HR 1.06; 95% CI 0.95-1.19). Significantly more patients assigned to darbepoetin experienced stroke and VTE, and significantly fewer patients required red-cell transfusions.

Bottom line: Darbepoetin use in patients with diabetes and CKD who do not require dialysis for correction of anemia does not improve clinical outcomes, and carries an increased risk of stroke and VTE.

Citation: Pfeffer MA, Burdmann EA, Chen CY, et al. A trial of darbepoetin alfa in type 2 diabetes and chronic kidney disease. N Engl J Med. 2009;361(21):2019-2032.

Reviewed for TH eWire Charles Baillie, MD, Elizabeth Marandola, MSN, ARNP, Janelle Ocampo, PharmD, BCPS, Craig A. Umscheid, MD, MSCE, Section of Hospital Medicine, Hospital of the University of Pennsylvania, Philadelphia.

For more HM-related research reviews, visit the "In the Literature" section of our Web site.

Clinical question: Does darbepoetin alfa use in patients with diabetes and chronic kidney disease (CKD) who do not require dialysis decrease the risk of death and cardiovascular or renal events?

Background: Anemia is a risk factor for cardiovascular and renal outcomes. The use of erythropoiesis-stimulating agents (ESAs) to increase hemoglobin reduces the need for transfusions and moderately improves quality of life. A placebo-controlled trial to determine if correction of anemia with ESAs improves clinical outcomes has not been conducted.

Study design: Randomized, double-blind, placebo-controlled trial.

Setting: 623 sites in 24 countries.

Synopsis: The study team randomized 4,038 patients to receive either dose-adjusted darbepoetin alfa (goal hemoglobin of 13) or placebo, with rescue doses of darbepoetin for hemoglobin below 9g/dL. The primary endpoints were a composite outcome of death, a cardiovascular event and death, or end-stage renal disease.

The median hemoglobin achieved in the darbepoetin and placebo groups were 12.5g/dL and 10.6g/dL, respectively. The primary cardiovascular endpoint occurred in 31.4% of patients receiving darbepoetin and 29.7% of patients receiving placebo (HR 1.05; 95% CI, 0.94-1.17). The primary renal endpoint occurred in 32.4% of patients assigned to darbepoetin and 30.5% of patients assigned to placebo (HR 1.06; 95% CI 0.95-1.19). Significantly more patients assigned to darbepoetin experienced stroke and VTE, and significantly fewer patients required red-cell transfusions.

Bottom line: Darbepoetin use in patients with diabetes and CKD who do not require dialysis for correction of anemia does not improve clinical outcomes, and carries an increased risk of stroke and VTE.

Citation: Pfeffer MA, Burdmann EA, Chen CY, et al. A trial of darbepoetin alfa in type 2 diabetes and chronic kidney disease. N Engl J Med. 2009;361(21):2019-2032.

Reviewed for TH eWire Charles Baillie, MD, Elizabeth Marandola, MSN, ARNP, Janelle Ocampo, PharmD, BCPS, Craig A. Umscheid, MD, MSCE, Section of Hospital Medicine, Hospital of the University of Pennsylvania, Philadelphia.

For more HM-related research reviews, visit the "In the Literature" section of our Web site.

Clinical question: Does darbepoetin alfa use in patients with diabetes and chronic kidney disease (CKD) who do not require dialysis decrease the risk of death and cardiovascular or renal events?

Background: Anemia is a risk factor for cardiovascular and renal outcomes. The use of erythropoiesis-stimulating agents (ESAs) to increase hemoglobin reduces the need for transfusions and moderately improves quality of life. A placebo-controlled trial to determine if correction of anemia with ESAs improves clinical outcomes has not been conducted.

Study design: Randomized, double-blind, placebo-controlled trial.

Setting: 623 sites in 24 countries.

Synopsis: The study team randomized 4,038 patients to receive either dose-adjusted darbepoetin alfa (goal hemoglobin of 13) or placebo, with rescue doses of darbepoetin for hemoglobin below 9g/dL. The primary endpoints were a composite outcome of death, a cardiovascular event and death, or end-stage renal disease.

The median hemoglobin achieved in the darbepoetin and placebo groups were 12.5g/dL and 10.6g/dL, respectively. The primary cardiovascular endpoint occurred in 31.4% of patients receiving darbepoetin and 29.7% of patients receiving placebo (HR 1.05; 95% CI, 0.94-1.17). The primary renal endpoint occurred in 32.4% of patients assigned to darbepoetin and 30.5% of patients assigned to placebo (HR 1.06; 95% CI 0.95-1.19). Significantly more patients assigned to darbepoetin experienced stroke and VTE, and significantly fewer patients required red-cell transfusions.

Bottom line: Darbepoetin use in patients with diabetes and CKD who do not require dialysis for correction of anemia does not improve clinical outcomes, and carries an increased risk of stroke and VTE.

Citation: Pfeffer MA, Burdmann EA, Chen CY, et al. A trial of darbepoetin alfa in type 2 diabetes and chronic kidney disease. N Engl J Med. 2009;361(21):2019-2032.

Reviewed for TH eWire Charles Baillie, MD, Elizabeth Marandola, MSN, ARNP, Janelle Ocampo, PharmD, BCPS, Craig A. Umscheid, MD, MSCE, Section of Hospital Medicine, Hospital of the University of Pennsylvania, Philadelphia.

For more HM-related research reviews, visit the "In the Literature" section of our Web site.

A supplement to Skin & Allergy News. This supplement was sponsored by Ferndale Laboratories Inc. and Primus Pharmaceuticals, makers of Aloquin Gel and Alcortin A Gel.

• Back to Basics: Recognizing and Treating Common Cutaneous Pathogens
• Diagnosis
• Considerations in Choosing Therapy
• Maximizing Treatment Success
• Counseling Patients About Preventing Infection and Transmission

Faculty/Faculty Disclosure

Jacquelyn B. Garrett, MD, FAAD

Diplomate, American Board of Dermatology,
Dermatology private practice at Christian Hospital,
St. Louis, MO

Dr. Garrett has nothing to disclose.
Copyright (C) 2009 Elsevier Inc.

To view the supplement, click the image above.

A supplement to Skin & Allergy News. This supplement was sponsored by Ferndale Laboratories Inc. and Primus Pharmaceuticals, makers of Aloquin Gel and Alcortin A Gel.

• Back to Basics: Recognizing and Treating Common Cutaneous Pathogens
• Diagnosis
• Considerations in Choosing Therapy
• Maximizing Treatment Success
• Counseling Patients About Preventing Infection and Transmission

Faculty/Faculty Disclosure

Jacquelyn B. Garrett, MD, FAAD

Diplomate, American Board of Dermatology,
Dermatology private practice at Christian Hospital,
St. Louis, MO

Dr. Garrett has nothing to disclose.
Copyright (C) 2009 Elsevier Inc.

To view the supplement, click the image above.

A supplement to Skin & Allergy News. This supplement was sponsored by Ferndale Laboratories Inc. and Primus Pharmaceuticals, makers of Aloquin Gel and Alcortin A Gel.

• Back to Basics: Recognizing and Treating Common Cutaneous Pathogens
• Diagnosis
• Considerations in Choosing Therapy
• Maximizing Treatment Success
• Counseling Patients About Preventing Infection and Transmission

Faculty/Faculty Disclosure

Jacquelyn B. Garrett, MD, FAAD

Diplomate, American Board of Dermatology,
Dermatology private practice at Christian Hospital,
St. Louis, MO

Dr. Garrett has nothing to disclose.
Copyright (C) 2009 Elsevier Inc.

To view the supplement, click the image above.

With prods from technological advancement and political pressure, the use of digital medicine is expected to take another leap forward this year—and hospitalists can be among those who benefit most, according to a presentation at an American College of Physicians meeting last month.

The workshop, "Wired and Wireless Health," held as part of the New Jersey Chapter regional meeting in Woodbridge, N.J., focused on three areas of health information technology (IT): social networking, applications and devices, and infrastructure. Steven Peskin, MD, MBA, FACP, says social networking Web sites like Sermo and Medscape Physician Connect offer portals for the "sharing of clinical insights and solutions to practical clinical problems in a way that promises to hone best practices."

As executive vice president and chief medical officer of Yardley, Pa.-based MediMedia USA, Dr. Peskin preaches the value of digital technology for inpatient care. Hospitalists, in particular, can use handheld devices and applications to deliver faster care and receive test results more quickly.

“There’s an app for that,” he quips, noting Modality and MedCalc. SHM is nearing launch of its new mobile resource center, which is supported by Epocrates and offers hospitalists exclusive commentary on the latest news and research in HM and hospitalist practice management.

Dr. Peskin, while an ardent supporter of the use of digital technology to improve patient care, is quick to caution that technology has its place. Privacy concerns, which are often associated with electronic health records (EHR), are a major consideration physicians should keep in mind when incorporating advances in iPhones, BlackBerrys, or other smartphones, he says.

"Digital medicine is not a substitute for clinical experience," Dr. Peskin says. "But it can improve clinical judgment and better clinical judgment. I like to say, 'Use computers for what they do well and use your brain for what it does well.'"

With prods from technological advancement and political pressure, the use of digital medicine is expected to take another leap forward this year—and hospitalists can be among those who benefit most, according to a presentation at an American College of Physicians meeting last month.

The workshop, "Wired and Wireless Health," held as part of the New Jersey Chapter regional meeting in Woodbridge, N.J., focused on three areas of health information technology (IT): social networking, applications and devices, and infrastructure. Steven Peskin, MD, MBA, FACP, says social networking Web sites like Sermo and Medscape Physician Connect offer portals for the "sharing of clinical insights and solutions to practical clinical problems in a way that promises to hone best practices."

As executive vice president and chief medical officer of Yardley, Pa.-based MediMedia USA, Dr. Peskin preaches the value of digital technology for inpatient care. Hospitalists, in particular, can use handheld devices and applications to deliver faster care and receive test results more quickly.

“There’s an app for that,” he quips, noting Modality and MedCalc. SHM is nearing launch of its new mobile resource center, which is supported by Epocrates and offers hospitalists exclusive commentary on the latest news and research in HM and hospitalist practice management.

Dr. Peskin, while an ardent supporter of the use of digital technology to improve patient care, is quick to caution that technology has its place. Privacy concerns, which are often associated with electronic health records (EHR), are a major consideration physicians should keep in mind when incorporating advances in iPhones, BlackBerrys, or other smartphones, he says.

"Digital medicine is not a substitute for clinical experience," Dr. Peskin says. "But it can improve clinical judgment and better clinical judgment. I like to say, 'Use computers for what they do well and use your brain for what it does well.'"

With prods from technological advancement and political pressure, the use of digital medicine is expected to take another leap forward this year—and hospitalists can be among those who benefit most, according to a presentation at an American College of Physicians meeting last month.

The workshop, "Wired and Wireless Health," held as part of the New Jersey Chapter regional meeting in Woodbridge, N.J., focused on three areas of health information technology (IT): social networking, applications and devices, and infrastructure. Steven Peskin, MD, MBA, FACP, says social networking Web sites like Sermo and Medscape Physician Connect offer portals for the "sharing of clinical insights and solutions to practical clinical problems in a way that promises to hone best practices."

As executive vice president and chief medical officer of Yardley, Pa.-based MediMedia USA, Dr. Peskin preaches the value of digital technology for inpatient care. Hospitalists, in particular, can use handheld devices and applications to deliver faster care and receive test results more quickly.

“There’s an app for that,” he quips, noting Modality and MedCalc. SHM is nearing launch of its new mobile resource center, which is supported by Epocrates and offers hospitalists exclusive commentary on the latest news and research in HM and hospitalist practice management.

Dr. Peskin, while an ardent supporter of the use of digital technology to improve patient care, is quick to caution that technology has its place. Privacy concerns, which are often associated with electronic health records (EHR), are a major consideration physicians should keep in mind when incorporating advances in iPhones, BlackBerrys, or other smartphones, he says.

"Digital medicine is not a substitute for clinical experience," Dr. Peskin says. "But it can improve clinical judgment and better clinical judgment. I like to say, 'Use computers for what they do well and use your brain for what it does well.'"

The oft-quoted Hippocrates once stated that physicians should be “clean in person, well-dressed, and anointed with sweet-smelling unguents.” So are hospitalists heeding the father of modern medicine’s counsel about physician appearance in the 21st century?

According to an informal survey about workplace attire conducted recently at the-hospitalist.org, a majority of hospitalists are wearing professional apparel while on the job.

In response to the question "What do you typically wear to work?" more than half (54%) of voters said they dress business casual, commonly defined as a dress shirt, slacks, belt, shoes, and socks for men, and a dress shirt, reasonable-length skirt or full-length trousers, shoes, and hosiery for women. Another 13% stated they wear a suit to work. Meanwhile, the other third of respondents said they dress in scrubs (22%), khakis and polo shirts (10%), and jeans and T-shirts (2%).

Most hospitalists at IPC: The Hospitalist Co., a national physician group practice based in North Hollywood, Calif., opt for business-casual dress, says Rafael Barretto, DO, the company's associate medical director for the Michigan region. While IPC does not have a strict dress code, it does give guidelines to its hospitalists and encourages them to avoid wearing sandals, tennis shoes, and jeans to work.

"IPC considers patients' attitudes on physician appearance to be very important. We want our patients to trust that we're going to do the best we can to take care of them," says Dr. Barretto, who cites several research studies, including a report published in the November 2005 issue of The American Journal of Medicine, that found patients favor physicians in professional attire.

"Fortunately or unfortunately, perception is reality and hospitalists need to be concerned with how a patient or a patient's family perceives them," says Chris Frost, MD, senior vice president of hospital medicine for TeamHealth Hospital Medicine, a national hospitalist management company in Knoxville, Tenn. TeamHealth has a company-wide policy that discourages its physicians from engaging in unprofessional dress.

"Hospitalists only have one chance to make a first impression. If a hospitalist is dressed poorly, that could overshadow any good patient care he or she provides," Dr. Frost says.

The oft-quoted Hippocrates once stated that physicians should be “clean in person, well-dressed, and anointed with sweet-smelling unguents.” So are hospitalists heeding the father of modern medicine’s counsel about physician appearance in the 21st century?

According to an informal survey about workplace attire conducted recently at the-hospitalist.org, a majority of hospitalists are wearing professional apparel while on the job.

In response to the question "What do you typically wear to work?" more than half (54%) of voters said they dress business casual, commonly defined as a dress shirt, slacks, belt, shoes, and socks for men, and a dress shirt, reasonable-length skirt or full-length trousers, shoes, and hosiery for women. Another 13% stated they wear a suit to work. Meanwhile, the other third of respondents said they dress in scrubs (22%), khakis and polo shirts (10%), and jeans and T-shirts (2%).

Most hospitalists at IPC: The Hospitalist Co., a national physician group practice based in North Hollywood, Calif., opt for business-casual dress, says Rafael Barretto, DO, the company's associate medical director for the Michigan region. While IPC does not have a strict dress code, it does give guidelines to its hospitalists and encourages them to avoid wearing sandals, tennis shoes, and jeans to work.

"IPC considers patients' attitudes on physician appearance to be very important. We want our patients to trust that we're going to do the best we can to take care of them," says Dr. Barretto, who cites several research studies, including a report published in the November 2005 issue of The American Journal of Medicine, that found patients favor physicians in professional attire.

"Fortunately or unfortunately, perception is reality and hospitalists need to be concerned with how a patient or a patient's family perceives them," says Chris Frost, MD, senior vice president of hospital medicine for TeamHealth Hospital Medicine, a national hospitalist management company in Knoxville, Tenn. TeamHealth has a company-wide policy that discourages its physicians from engaging in unprofessional dress.

"Hospitalists only have one chance to make a first impression. If a hospitalist is dressed poorly, that could overshadow any good patient care he or she provides," Dr. Frost says.

The oft-quoted Hippocrates once stated that physicians should be “clean in person, well-dressed, and anointed with sweet-smelling unguents.” So are hospitalists heeding the father of modern medicine’s counsel about physician appearance in the 21st century?

According to an informal survey about workplace attire conducted recently at the-hospitalist.org, a majority of hospitalists are wearing professional apparel while on the job.

In response to the question "What do you typically wear to work?" more than half (54%) of voters said they dress business casual, commonly defined as a dress shirt, slacks, belt, shoes, and socks for men, and a dress shirt, reasonable-length skirt or full-length trousers, shoes, and hosiery for women. Another 13% stated they wear a suit to work. Meanwhile, the other third of respondents said they dress in scrubs (22%), khakis and polo shirts (10%), and jeans and T-shirts (2%).

Most hospitalists at IPC: The Hospitalist Co., a national physician group practice based in North Hollywood, Calif., opt for business-casual dress, says Rafael Barretto, DO, the company's associate medical director for the Michigan region. While IPC does not have a strict dress code, it does give guidelines to its hospitalists and encourages them to avoid wearing sandals, tennis shoes, and jeans to work.

"IPC considers patients' attitudes on physician appearance to be very important. We want our patients to trust that we're going to do the best we can to take care of them," says Dr. Barretto, who cites several research studies, including a report published in the November 2005 issue of The American Journal of Medicine, that found patients favor physicians in professional attire.

"Fortunately or unfortunately, perception is reality and hospitalists need to be concerned with how a patient or a patient's family perceives them," says Chris Frost, MD, senior vice president of hospital medicine for TeamHealth Hospital Medicine, a national hospitalist management company in Knoxville, Tenn. TeamHealth has a company-wide policy that discourages its physicians from engaging in unprofessional dress.

"Hospitalists only have one chance to make a first impression. If a hospitalist is dressed poorly, that could overshadow any good patient care he or she provides," Dr. Frost says.

Click here to listen to the audio file

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Dr. Jaffer discusses HM10 keynote speakers Paul Levy and Bob Wachter

Click here to listen to the audio.

Dr. Jaffer explains what the average hospitalist should expect at HM10 in Washington, D.C.

Click here to listen to the audio.

Dr. Jaffer discusses how the national healthcare reform debate will backdrop HM10, and how new peer-reviewed, seat-limited workshops will enhance the HM10 experience.

Click here to listen to the audio.

Dr. Jaffer explains how first-time HM10 attendees can maximize their time in D.C.

Click here to listen to the audio.

Dr. Jaffer discusses HM10 keynote speakers Paul Levy and Bob Wachter

Click here to listen to the audio.

Dr. Jaffer explains what the average hospitalist should expect at HM10 in Washington, D.C.

Click here to listen to the audio.

Dr. Jaffer discusses how the national healthcare reform debate will backdrop HM10, and how new peer-reviewed, seat-limited workshops will enhance the HM10 experience.

Click here to listen to the audio.

Dr. Jaffer explains how first-time HM10 attendees can maximize their time in D.C.

Click here to listen to the audio.

Dr. Jaffer discusses HM10 keynote speakers Paul Levy and Bob Wachter

Click here to listen to the audio.

Dr. Jaffer explains what the average hospitalist should expect at HM10 in Washington, D.C.

Click here to listen to the audio.

Dr. Jaffer discusses how the national healthcare reform debate will backdrop HM10, and how new peer-reviewed, seat-limited workshops will enhance the HM10 experience.

Click here to listen to the audio.

Dr. Jaffer explains how first-time HM10 attendees can maximize their time in D.C.

Click here to listen to the audio.

Massachusetts Update

With the ongoing debate about healthcare reform, I’m curious to know how it worked out in Massachusetts. Didn’t they give everyone health insurance several years ago?

R. McCoy, MD

Birmingham, Ala.

Dr. Hospitalist responds: In 2006, Massachusetts legislators took the same approach to healthcare insurance as they do to auto insurance: require everyone to purchase a plan. If you can’t afford to purchase health insurance, the state provides you insurance through a state-subsidized plan. The state covers individuals earning up to 100% of the federal poverty level (FPL) and partially subsidizes coverage for those earning up to 300% of the FPL.

So how did Massachusetts come up with the money to pay for healthcare insurance for all of its residents? The state traditionally utilized money from a “free-care pool” to partially reimburse hospitals and community health centers for the care provided to indigents. The money in the free-care pool was generated from state and federal taxes, and from assessments on hospitals and healthcare insurance providers. With expanded insurance coverage, Massachusetts estimated that the cost of healthcare delivered to the uninsured would decrease, and the free-care pool could offset the remaining costs of insuring those below the FPL.

Starting in 2007, residents of Massachusetts were required to demonstrate proof of health insurance on their state income tax returns. The state levied penalties on those who failed to obtain coverage. The legislation also required insurers’ family plans to cover young adults up to age 25 or at least two years after they were no longer dependent on their parents. Additionally, businesses with 10 or more employees had to contribute a reasonable amount to their employees’ health insurance premiums or risk a financial penalty.

The Massachusetts health plan has produced both intended and unintended consequences. The plan was successful in its primary goal of insuring its citizens. By the end of 2008, 97% of Massachusetts’ residents were covered. But the system has not increased access to providers because of a shortage of primary-care physicians (PCPs). (Critics also point out that the plan has done nothing to increase the numbers of PCPs in the state.)

Another unexpected outcome is that healthcare costs have increased. The initial expectation was that increasing the percentage of insured individuals would lower overall costs. However, this has not been realized. In fact, the reallocation of funds from the free-care pool has birthed other problems. The state’s “safety net” hospitals—which traditionally have served urban, low-income populations—have experienced financial hardships.

These unexpected findings have not deterred Massachusetts from further efforts to address healthcare reform. In 2008, a special commission was charged with recommendations for a “common payment methodology” that would apply to both public and private payors. The goal is to slow the growth of healthcare costs without adversely affecting the quality of care.

The commission issued its recommendations in July 2009 (www.mass.gov). It suggested “Massachusetts has among the highest healthcare costs in the U.S. … and based on recent history, are projected to grow faster than for the U.S. as a whole.” In its report, the commission was critical of the present fee-for-service reimbursement model and stated that the model was the primary reason for escalating healthcare costs.

The commission noted the fee-for-service model rewards providers for providing more, but not better, care and also encourages providers to provide more-costly services without regard to evidence-based guidelines or a patient’s need. The commission recommended that “global payments with adjustments to reward provision of accessible and high-quality care become the predominant form of payment to providers in Massachusetts.” For the record, the legislature has not acted on the commission recommendations. TH

IMAGE SOURCE: AMANE KANEKO

Massachusetts Update

With the ongoing debate about healthcare reform, I’m curious to know how it worked out in Massachusetts. Didn’t they give everyone health insurance several years ago?

R. McCoy, MD

Birmingham, Ala.

Dr. Hospitalist responds: In 2006, Massachusetts legislators took the same approach to healthcare insurance as they do to auto insurance: require everyone to purchase a plan. If you can’t afford to purchase health insurance, the state provides you insurance through a state-subsidized plan. The state covers individuals earning up to 100% of the federal poverty level (FPL) and partially subsidizes coverage for those earning up to 300% of the FPL.

So how did Massachusetts come up with the money to pay for healthcare insurance for all of its residents? The state traditionally utilized money from a “free-care pool” to partially reimburse hospitals and community health centers for the care provided to indigents. The money in the free-care pool was generated from state and federal taxes, and from assessments on hospitals and healthcare insurance providers. With expanded insurance coverage, Massachusetts estimated that the cost of healthcare delivered to the uninsured would decrease, and the free-care pool could offset the remaining costs of insuring those below the FPL.

Starting in 2007, residents of Massachusetts were required to demonstrate proof of health insurance on their state income tax returns. The state levied penalties on those who failed to obtain coverage. The legislation also required insurers’ family plans to cover young adults up to age 25 or at least two years after they were no longer dependent on their parents. Additionally, businesses with 10 or more employees had to contribute a reasonable amount to their employees’ health insurance premiums or risk a financial penalty.

The Massachusetts health plan has produced both intended and unintended consequences. The plan was successful in its primary goal of insuring its citizens. By the end of 2008, 97% of Massachusetts’ residents were covered. But the system has not increased access to providers because of a shortage of primary-care physicians (PCPs). (Critics also point out that the plan has done nothing to increase the numbers of PCPs in the state.)

Another unexpected outcome is that healthcare costs have increased. The initial expectation was that increasing the percentage of insured individuals would lower overall costs. However, this has not been realized. In fact, the reallocation of funds from the free-care pool has birthed other problems. The state’s “safety net” hospitals—which traditionally have served urban, low-income populations—have experienced financial hardships.

These unexpected findings have not deterred Massachusetts from further efforts to address healthcare reform. In 2008, a special commission was charged with recommendations for a “common payment methodology” that would apply to both public and private payors. The goal is to slow the growth of healthcare costs without adversely affecting the quality of care.

The commission issued its recommendations in July 2009 (www.mass.gov). It suggested “Massachusetts has among the highest healthcare costs in the U.S. … and based on recent history, are projected to grow faster than for the U.S. as a whole.” In its report, the commission was critical of the present fee-for-service reimbursement model and stated that the model was the primary reason for escalating healthcare costs.

The commission noted the fee-for-service model rewards providers for providing more, but not better, care and also encourages providers to provide more-costly services without regard to evidence-based guidelines or a patient’s need. The commission recommended that “global payments with adjustments to reward provision of accessible and high-quality care become the predominant form of payment to providers in Massachusetts.” For the record, the legislature has not acted on the commission recommendations. TH

IMAGE SOURCE: AMANE KANEKO

Massachusetts Update

With the ongoing debate about healthcare reform, I’m curious to know how it worked out in Massachusetts. Didn’t they give everyone health insurance several years ago?

R. McCoy, MD

Birmingham, Ala.

Dr. Hospitalist responds: In 2006, Massachusetts legislators took the same approach to healthcare insurance as they do to auto insurance: require everyone to purchase a plan. If you can’t afford to purchase health insurance, the state provides you insurance through a state-subsidized plan. The state covers individuals earning up to 100% of the federal poverty level (FPL) and partially subsidizes coverage for those earning up to 300% of the FPL.

So how did Massachusetts come up with the money to pay for healthcare insurance for all of its residents? The state traditionally utilized money from a “free-care pool” to partially reimburse hospitals and community health centers for the care provided to indigents. The money in the free-care pool was generated from state and federal taxes, and from assessments on hospitals and healthcare insurance providers. With expanded insurance coverage, Massachusetts estimated that the cost of healthcare delivered to the uninsured would decrease, and the free-care pool could offset the remaining costs of insuring those below the FPL.

Starting in 2007, residents of Massachusetts were required to demonstrate proof of health insurance on their state income tax returns. The state levied penalties on those who failed to obtain coverage. The legislation also required insurers’ family plans to cover young adults up to age 25 or at least two years after they were no longer dependent on their parents. Additionally, businesses with 10 or more employees had to contribute a reasonable amount to their employees’ health insurance premiums or risk a financial penalty.

The Massachusetts health plan has produced both intended and unintended consequences. The plan was successful in its primary goal of insuring its citizens. By the end of 2008, 97% of Massachusetts’ residents were covered. But the system has not increased access to providers because of a shortage of primary-care physicians (PCPs). (Critics also point out that the plan has done nothing to increase the numbers of PCPs in the state.)

Another unexpected outcome is that healthcare costs have increased. The initial expectation was that increasing the percentage of insured individuals would lower overall costs. However, this has not been realized. In fact, the reallocation of funds from the free-care pool has birthed other problems. The state’s “safety net” hospitals—which traditionally have served urban, low-income populations—have experienced financial hardships.

These unexpected findings have not deterred Massachusetts from further efforts to address healthcare reform. In 2008, a special commission was charged with recommendations for a “common payment methodology” that would apply to both public and private payors. The goal is to slow the growth of healthcare costs without adversely affecting the quality of care.

The commission issued its recommendations in July 2009 (www.mass.gov). It suggested “Massachusetts has among the highest healthcare costs in the U.S. … and based on recent history, are projected to grow faster than for the U.S. as a whole.” In its report, the commission was critical of the present fee-for-service reimbursement model and stated that the model was the primary reason for escalating healthcare costs.

The commission noted the fee-for-service model rewards providers for providing more, but not better, care and also encourages providers to provide more-costly services without regard to evidence-based guidelines or a patient’s need. The commission recommended that “global payments with adjustments to reward provision of accessible and high-quality care become the predominant form of payment to providers in Massachusetts.” For the record, the legislature has not acted on the commission recommendations. TH

IMAGE SOURCE: AMANE KANEKO

Editor’s note: Second of a three-part series.

As I mentioned last month, there isn’t a proven best method to use when distributing new referrals among your group’s providers. The popular methods fall along a continuum of being focused on daily, or continuous, leveling of patient loads between providers (“load leveling”) at one end; at the other end of the continuum is having a doctor be “on” for all new referrals for a predetermined time period, and accepting that patient volumes might be uneven day to day but tend to even out over long periods.

There might not be any reason to change your group’s approach to patient assignment, but you should always be thinking about how your own methods might be changed or improved. I have shared (“Bigger Isn’t Always Better,” June 2009, p. 46) my concern that some groups invest far too much time in a morning load-leveling and handoff conference. Make sure your group is using only as much time as needed.

Air-Traffic Controllers

Many large groups (e.g., more than 15 full-time equivalents) that assign patients to providers in sequence, like dealing a deck of cards, have a designated provider who holds the triage pager and serves as “air-traffic controller.” This person typically takes incoming calls about all new referrals, jots down the relevant clinical data, keeps track of which hospitalist is due to take the next patient, pages that person, and repeats the clinical information. As I’ve written before (“How to Hire and Use Clerical Staff,” June 2007, p. 73), many practices have found that during business hours, they can hand this role to a clerical person who simply takes down the name and phone number of the doctor making the referral, then pages that information to the hospitalist due to get the next patient. The hospitalist then calls and speaks directly with the referring doctor.

Small- to medium-sized groups can eliminate entirely the need for any such “air-traffic control” function if they assign all new referrals to a single doctor for specified periods of time. For example, from 7 a.m. to 3 p.m. today, all new referrals go to Dr. Glass, and from 3 p.m. to 11 p.m., they go to Dr. Cage.

Admitter-Rounder Duties

Many—maybe most?—large groups separate daytime admitter and rounder functions so that on any given day, a hospitalist does one but not both. The principal advantages of this approach are reducing the stress on, and possibly increasing the efficiency of, rounding doctors by shielding them from the unpredictable and time-consuming interruption of needing to admit a new patient. And a daytime doctor who only does admissions might be able to start seeing a patient in the ED more quickly than one who is busy making rounds.

Any increased availability of admitters to the ED could be offset by their lack of surge capacity leading to a bottleneck in ED throughput when there are many patients to admit at the same time and a limited number of admitters (often only one). Such a bottleneck would be much less likely if all daytime doctors (i.e., the rounders) were available to see admissions rather than just admitters.

Continuity of care suffers when a group has separate admitters and rounders, because no patients will be seen by the same doctor on the day of admission and the day following. This method requires a handoff from the day of admission to the next day. Such a handoff might be unavoidable for patients admitted during the night, but this doesn’t have to occur when patients are admitted during the daytime.

Who’s Seeing this Patient?

It seems to make sense to wait until each morning to distribute patients. That allows the practice to know just how many new patients there are, and they can be distributed according to complexity and whether a hospitalist has formed a previous relationship with that patient. But it means that no one at the hospital will know which hospitalist is caring for the patient until later in the morning. For example, if the radiologist is over-reading a study done during the night and finds something worthy of a phone call to the hospitalist, no one is sure who should get the call. A patient might develop hypoglycemia shortly after the hospitalist night shift is over, but the nurse doesn’t know which hospitalist to call.

And, perhaps most importantly, if patients aren’t distributed until the start of the day shift, the night hospitalist can’t tell the patient and family which hospitalist to expect the next morning. To test the significance of this issue, I conducted an experiment while working our group’s late-evening admitter shift. I concluded my visit with each admitted patient by explaining, “I am on-call for our group tonight, so I will be off recovering tomorrow. Therefore, I won’t see you again, but one of my partners will take over in the morning. Do you have any questions for me?” Every patient I admitted had the same question. “What is that doctor’s name?”

How does your group answer a patient who asks which hospitalist will be in the next day? If your method is load-leveling in the morning, then the best answer your night admitting doctor can give is probably to say: “I don’t know which of my partners will be in. There are several working tomorrow, and at the start of the day, they will divide up the patients who come in tonight depending on how busy each of them is. But all the doctors in our group are terrific and will take good care of you.”

I’m told the same thing when I get my hair cut: You’ll get whichever “hair artist” is up next. I put up with it at the hair place because it costs less than $15. But I still find it a little irritating. I’m sure all the barbers aren’t equally skilled or diligent, and I want the best one. (Maybe I shouldn’t care since there isn’t much that can be done with my hair.) I’m pretty sure patients feel the same way about which doctor they get. The public is convinced there is a wide variety in the quality of doctors, and they want a good one. If you have to tell them theirs is being assigned by lottery, they won’t be as happy than if you can provide the name and a little information about the doctor they can expect to see the next day.

When the patients I admit late last evening ask who would see them the next day, I’m glad when I can provide a name and a little more information. I say something like, “I won’t see you after tonight, but my partner, Dr. Shawn Lee, will be instead. That means you’re getting an upgrade! Not only is he a really nice guy, he’s voted one of Seattle’s best doctors every year. He’ll do a great job for you.”

To make this communication effective, the night doctor has to know which hospitalist takes over the next morning and has a list indicating which day doctor will get the first, second, third new patient, and so on, admitted during the night. This is possible if patients are assigned by a predetermined algorithm, or if the day doctors have their load-leveling meeting at the end of each day shift, rather than in the morning, to create a list telling the night doctor which day hospitalist he should admit the first and subsequent patents to. That way, the night doctor can write in the admitting orders at 1 a.m. “admit to Dr. X.” This eliminates confusion on the part of other hospital staff who need to know who to call about a patient after the start of the day shift.

Next month I will look at special circumstances, and some pros and cons of having an individual hospitalist take on the care of more patients at the beginning of consecutive day shifts, and exempting them from taking on new patients on the last day or two before rotating off. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

Editor’s note: Second of a three-part series.

As I mentioned last month, there isn’t a proven best method to use when distributing new referrals among your group’s providers. The popular methods fall along a continuum of being focused on daily, or continuous, leveling of patient loads between providers (“load leveling”) at one end; at the other end of the continuum is having a doctor be “on” for all new referrals for a predetermined time period, and accepting that patient volumes might be uneven day to day but tend to even out over long periods.

There might not be any reason to change your group’s approach to patient assignment, but you should always be thinking about how your own methods might be changed or improved. I have shared (“Bigger Isn’t Always Better,” June 2009, p. 46) my concern that some groups invest far too much time in a morning load-leveling and handoff conference. Make sure your group is using only as much time as needed.

Air-Traffic Controllers

Many large groups (e.g., more than 15 full-time equivalents) that assign patients to providers in sequence, like dealing a deck of cards, have a designated provider who holds the triage pager and serves as “air-traffic controller.” This person typically takes incoming calls about all new referrals, jots down the relevant clinical data, keeps track of which hospitalist is due to take the next patient, pages that person, and repeats the clinical information. As I’ve written before (“How to Hire and Use Clerical Staff,” June 2007, p. 73), many practices have found that during business hours, they can hand this role to a clerical person who simply takes down the name and phone number of the doctor making the referral, then pages that information to the hospitalist due to get the next patient. The hospitalist then calls and speaks directly with the referring doctor.

Small- to medium-sized groups can eliminate entirely the need for any such “air-traffic control” function if they assign all new referrals to a single doctor for specified periods of time. For example, from 7 a.m. to 3 p.m. today, all new referrals go to Dr. Glass, and from 3 p.m. to 11 p.m., they go to Dr. Cage.

Admitter-Rounder Duties

Many—maybe most?—large groups separate daytime admitter and rounder functions so that on any given day, a hospitalist does one but not both. The principal advantages of this approach are reducing the stress on, and possibly increasing the efficiency of, rounding doctors by shielding them from the unpredictable and time-consuming interruption of needing to admit a new patient. And a daytime doctor who only does admissions might be able to start seeing a patient in the ED more quickly than one who is busy making rounds.

Any increased availability of admitters to the ED could be offset by their lack of surge capacity leading to a bottleneck in ED throughput when there are many patients to admit at the same time and a limited number of admitters (often only one). Such a bottleneck would be much less likely if all daytime doctors (i.e., the rounders) were available to see admissions rather than just admitters.

Continuity of care suffers when a group has separate admitters and rounders, because no patients will be seen by the same doctor on the day of admission and the day following. This method requires a handoff from the day of admission to the next day. Such a handoff might be unavoidable for patients admitted during the night, but this doesn’t have to occur when patients are admitted during the daytime.

Who’s Seeing this Patient?

It seems to make sense to wait until each morning to distribute patients. That allows the practice to know just how many new patients there are, and they can be distributed according to complexity and whether a hospitalist has formed a previous relationship with that patient. But it means that no one at the hospital will know which hospitalist is caring for the patient until later in the morning. For example, if the radiologist is over-reading a study done during the night and finds something worthy of a phone call to the hospitalist, no one is sure who should get the call. A patient might develop hypoglycemia shortly after the hospitalist night shift is over, but the nurse doesn’t know which hospitalist to call.

And, perhaps most importantly, if patients aren’t distributed until the start of the day shift, the night hospitalist can’t tell the patient and family which hospitalist to expect the next morning. To test the significance of this issue, I conducted an experiment while working our group’s late-evening admitter shift. I concluded my visit with each admitted patient by explaining, “I am on-call for our group tonight, so I will be off recovering tomorrow. Therefore, I won’t see you again, but one of my partners will take over in the morning. Do you have any questions for me?” Every patient I admitted had the same question. “What is that doctor’s name?”

How does your group answer a patient who asks which hospitalist will be in the next day? If your method is load-leveling in the morning, then the best answer your night admitting doctor can give is probably to say: “I don’t know which of my partners will be in. There are several working tomorrow, and at the start of the day, they will divide up the patients who come in tonight depending on how busy each of them is. But all the doctors in our group are terrific and will take good care of you.”

I’m told the same thing when I get my hair cut: You’ll get whichever “hair artist” is up next. I put up with it at the hair place because it costs less than $15. But I still find it a little irritating. I’m sure all the barbers aren’t equally skilled or diligent, and I want the best one. (Maybe I shouldn’t care since there isn’t much that can be done with my hair.) I’m pretty sure patients feel the same way about which doctor they get. The public is convinced there is a wide variety in the quality of doctors, and they want a good one. If you have to tell them theirs is being assigned by lottery, they won’t be as happy than if you can provide the name and a little information about the doctor they can expect to see the next day.

When the patients I admit late last evening ask who would see them the next day, I’m glad when I can provide a name and a little more information. I say something like, “I won’t see you after tonight, but my partner, Dr. Shawn Lee, will be instead. That means you’re getting an upgrade! Not only is he a really nice guy, he’s voted one of Seattle’s best doctors every year. He’ll do a great job for you.”

To make this communication effective, the night doctor has to know which hospitalist takes over the next morning and has a list indicating which day doctor will get the first, second, third new patient, and so on, admitted during the night. This is possible if patients are assigned by a predetermined algorithm, or if the day doctors have their load-leveling meeting at the end of each day shift, rather than in the morning, to create a list telling the night doctor which day hospitalist he should admit the first and subsequent patents to. That way, the night doctor can write in the admitting orders at 1 a.m. “admit to Dr. X.” This eliminates confusion on the part of other hospital staff who need to know who to call about a patient after the start of the day shift.

Next month I will look at special circumstances, and some pros and cons of having an individual hospitalist take on the care of more patients at the beginning of consecutive day shifts, and exempting them from taking on new patients on the last day or two before rotating off. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

Editor’s note: Second of a three-part series.

As I mentioned last month, there isn’t a proven best method to use when distributing new referrals among your group’s providers. The popular methods fall along a continuum of being focused on daily, or continuous, leveling of patient loads between providers (“load leveling”) at one end; at the other end of the continuum is having a doctor be “on” for all new referrals for a predetermined time period, and accepting that patient volumes might be uneven day to day but tend to even out over long periods.

There might not be any reason to change your group’s approach to patient assignment, but you should always be thinking about how your own methods might be changed or improved. I have shared (“Bigger Isn’t Always Better,” June 2009, p. 46) my concern that some groups invest far too much time in a morning load-leveling and handoff conference. Make sure your group is using only as much time as needed.

Air-Traffic Controllers

Many large groups (e.g., more than 15 full-time equivalents) that assign patients to providers in sequence, like dealing a deck of cards, have a designated provider who holds the triage pager and serves as “air-traffic controller.” This person typically takes incoming calls about all new referrals, jots down the relevant clinical data, keeps track of which hospitalist is due to take the next patient, pages that person, and repeats the clinical information. As I’ve written before (“How to Hire and Use Clerical Staff,” June 2007, p. 73), many practices have found that during business hours, they can hand this role to a clerical person who simply takes down the name and phone number of the doctor making the referral, then pages that information to the hospitalist due to get the next patient. The hospitalist then calls and speaks directly with the referring doctor.

Small- to medium-sized groups can eliminate entirely the need for any such “air-traffic control” function if they assign all new referrals to a single doctor for specified periods of time. For example, from 7 a.m. to 3 p.m. today, all new referrals go to Dr. Glass, and from 3 p.m. to 11 p.m., they go to Dr. Cage.

Admitter-Rounder Duties

Many—maybe most?—large groups separate daytime admitter and rounder functions so that on any given day, a hospitalist does one but not both. The principal advantages of this approach are reducing the stress on, and possibly increasing the efficiency of, rounding doctors by shielding them from the unpredictable and time-consuming interruption of needing to admit a new patient. And a daytime doctor who only does admissions might be able to start seeing a patient in the ED more quickly than one who is busy making rounds.

Any increased availability of admitters to the ED could be offset by their lack of surge capacity leading to a bottleneck in ED throughput when there are many patients to admit at the same time and a limited number of admitters (often only one). Such a bottleneck would be much less likely if all daytime doctors (i.e., the rounders) were available to see admissions rather than just admitters.

Continuity of care suffers when a group has separate admitters and rounders, because no patients will be seen by the same doctor on the day of admission and the day following. This method requires a handoff from the day of admission to the next day. Such a handoff might be unavoidable for patients admitted during the night, but this doesn’t have to occur when patients are admitted during the daytime.

Who’s Seeing this Patient?

It seems to make sense to wait until each morning to distribute patients. That allows the practice to know just how many new patients there are, and they can be distributed according to complexity and whether a hospitalist has formed a previous relationship with that patient. But it means that no one at the hospital will know which hospitalist is caring for the patient until later in the morning. For example, if the radiologist is over-reading a study done during the night and finds something worthy of a phone call to the hospitalist, no one is sure who should get the call. A patient might develop hypoglycemia shortly after the hospitalist night shift is over, but the nurse doesn’t know which hospitalist to call.

And, perhaps most importantly, if patients aren’t distributed until the start of the day shift, the night hospitalist can’t tell the patient and family which hospitalist to expect the next morning. To test the significance of this issue, I conducted an experiment while working our group’s late-evening admitter shift. I concluded my visit with each admitted patient by explaining, “I am on-call for our group tonight, so I will be off recovering tomorrow. Therefore, I won’t see you again, but one of my partners will take over in the morning. Do you have any questions for me?” Every patient I admitted had the same question. “What is that doctor’s name?”

How does your group answer a patient who asks which hospitalist will be in the next day? If your method is load-leveling in the morning, then the best answer your night admitting doctor can give is probably to say: “I don’t know which of my partners will be in. There are several working tomorrow, and at the start of the day, they will divide up the patients who come in tonight depending on how busy each of them is. But all the doctors in our group are terrific and will take good care of you.”

I’m told the same thing when I get my hair cut: You’ll get whichever “hair artist” is up next. I put up with it at the hair place because it costs less than $15. But I still find it a little irritating. I’m sure all the barbers aren’t equally skilled or diligent, and I want the best one. (Maybe I shouldn’t care since there isn’t much that can be done with my hair.) I’m pretty sure patients feel the same way about which doctor they get. The public is convinced there is a wide variety in the quality of doctors, and they want a good one. If you have to tell them theirs is being assigned by lottery, they won’t be as happy than if you can provide the name and a little information about the doctor they can expect to see the next day.

When the patients I admit late last evening ask who would see them the next day, I’m glad when I can provide a name and a little more information. I say something like, “I won’t see you after tonight, but my partner, Dr. Shawn Lee, will be instead. That means you’re getting an upgrade! Not only is he a really nice guy, he’s voted one of Seattle’s best doctors every year. He’ll do a great job for you.”

To make this communication effective, the night doctor has to know which hospitalist takes over the next morning and has a list indicating which day doctor will get the first, second, third new patient, and so on, admitted during the night. This is possible if patients are assigned by a predetermined algorithm, or if the day doctors have their load-leveling meeting at the end of each day shift, rather than in the morning, to create a list telling the night doctor which day hospitalist he should admit the first and subsequent patents to. That way, the night doctor can write in the admitting orders at 1 a.m. “admit to Dr. X.” This eliminates confusion on the part of other hospital staff who need to know who to call about a patient after the start of the day shift.

Next month I will look at special circumstances, and some pros and cons of having an individual hospitalist take on the care of more patients at the beginning of consecutive day shifts, and exempting them from taking on new patients on the last day or two before rotating off. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

O K, I’ll admit it: I like football. Call me a Neanderthal, but there is nothing quite like an afternoon with friends watching a tightly contested game of titans battling it out on the gridiron. Back in January, I enjoyed that glorious weekend in which the NFC and AFC crown their respective champions, each sending a team of combatants to the Super Bowl.

Fully enjoying the Sunday afternoon of ambrosia requires tons of preparation. Practically speaking, this means clearing my schedule of such clutter as child-rearing and housekeeping, along with dispatching my wife to the store minutes before my friends arrive to procure a second-chin’s worth of kettle chips and a potomaniac’s quantity of cheap beer. Then I settle into the butt-dented comfort of my overworked couch, where I’m surrounded by a rowdy pack of friends.

During hour three of the pre-game analysis, I can’t help but notice that my lovely wife, neither a fan of football or my friends spilling beer on her couch, has contracted a nasty case of the angry stink-eye, which she wields like a laser beam through my skull. I ponder the cost that all of this revelry, last-minute dispatching, and spilled beer will have on my marriage. Concluding that I indeed have at least three paws in the doghouse, I reflect on the facts that a) my wife is a saint; b) she reads this column—honey, read point “a” again; and c) Valentine’s Day is right around the corner.

Oh, well. The game must go on, and right now, it’s all about the NFL—hard-hitting, back-and-forth, in-your-face, smash-mouth action. Unbeatable. Unbeatable, that is, until you realize that a typical football game contains a lot of things, except for much actual football.

The Facts on Football

A recent Wall Street Journal analysis of NFL playoff games reported that the typical football game consists of many things, but not much real action. In fact, the average three-plus-hour telecast consists of just 10 minutes and 43 seconds of play. After subtracting about an hour of commercials, the rest of an average telecast consists of such things as players standing around (67 minutes), replays (17 minutes), and, of course, the all-important shots of cheerleaders—which is allotted, remarkably, only three seconds per game. Seems like more.

In percentage terms, the pie is doled out this way: standing around (58.5%), replays (14.5%), playing time (9.4%), coach shots (4.9%), sideline player shots (3.4%), referee shots (2.4%), crowd shots (0.9%), and other miscellany, such as footage of owners in their high-priced luxury suites (0.3%), the kicker warming up (0.2%), and, of course, cheerleaders (0.1%).

While this level of inaction has an enabling effect on convivial taunting, bet-brokering, and beer runs, it is, to be frank, a laughably low amount of action. How can an entire industry be built on such a level of inactivity? It’s a great question—one that induces a momentary chuckle until I consider how I spend much of my clinical days.

Inactivity in the Workplace

A 2006 paper in the Journal of Hospital Medicine tackled the issue of hospitalist workflow.1 Researchers followed 10 academic hospitalists through various parts of a routine day, all the while measuring to the minute how they spent their time. What they found would be as astounding to hospital outsiders as the NFL data, should anyone ever find themselves so deep in the boredom pit to be watching a hospitalist make rounds.

Which made me wonder: What would Brett Favre, the Minnesota Vikings’ future Hall of Fame quarterback, think if he were watching me ply my trade? Which led me to further wonder how far afield Brett Favre’s life would have to be derailed for him to watch me round. Finally, it left me wondering why I don’t spend my time wondering about more productive things.

Anyway, if Brett were to watch one of us, this is what he’d see: The average hospitalist in this study spent only 18% of their time in direct-patient-care activities, including taking a patient history, examining a patient, and meeting with a patient’s family. Eighteen percent! Isn’t seeing patients why I became a doctor?

While it’s more time than Brett Favre spends slinging the pigskin, it’s still an astonishingly low amount of time actually working with patients. Then there’s the “indirect patient care” category (e.g., reviewing tests, writing notes, making orders), where we spend 69% of our day. This is our time in the huddle, so to speak: lots of planning, little action. Further, these academic hospitalists spent 4% of their time on personal activities (e.g., lunch, bathroom breaks), and 3% of their time in each of the following endeavors: professional development (learning, conferences), teaching, and traveling from floor to floor seeing patients.

Another revealing find was that the average hospitalist spent 6% of their time paging other physicians and 7% returning pages from others (the average hospitalist received 3.4 pages an hour). That’s 13% of the day spent on the phone, or waiting for a phone to ring. That’s about 1.5 hours of a typical 12-hour shift. Over the course of a year, that equates to about 300 hours of time (25 shifts) spent in the paging process. If we could find a way to totally remove the paging process from hospital communication, the average hospitalist could accomplish the same amount of work they do now, and take an additional 20-25 days off per year. Perhaps we should wear high-tech helmets—you know, the kind quarterbacks like Brett Favre use to communicate with his coaches on the sidelines.

Efficient Solutions

Before my hospitalists hit me up for wireless communication devices and an extra three weeks of vacation, understand that much of the paging downtime likely is used for multitasking. In fact, in the study, 21% of a hospitalist’s time was spent working on more than one endeavor. Still, my experience tells me that there is a lot of time lost in the paging vortex.

Furthermore, the 3% of time hospitalists spent walking to other floors, 5% spent on discharge paperwork, and 1% of time spent on routine clerical work (did the researchers inadvertently report 1% instead of 10%?) adds up to nearly a tenth of the day that is either wasted, could be automated, or could be completed by ancillary staff.

To be clear, this happens through no fault of individual hospitalists. Rather, it results from the inefficiency of hospital care systems. And if we endeavor to enhance the revenue, efficiency, and satisfaction of our providers, we need to re-engineer our systems to alter that vast expanse of time spent on inactivity and inefficiency. This means adopting new modes of communication, moving toward geographic rounds, and generally retooling our operational inefficiencies.

Short of that, we risk becoming as idle as the NFL—without the cheerleaders. TH

Dr. Glasheen is The Hospitalist’s physician editor.

Reference

1. O’Leary KJ, Liebovitz DM, Baker DW. How hospitalists spend their time: insights on efficiency and safety. J Hosp Med. 2006;1(2):88-93.

O K, I’ll admit it: I like football. Call me a Neanderthal, but there is nothing quite like an afternoon with friends watching a tightly contested game of titans battling it out on the gridiron. Back in January, I enjoyed that glorious weekend in which the NFC and AFC crown their respective champions, each sending a team of combatants to the Super Bowl.

Fully enjoying the Sunday afternoon of ambrosia requires tons of preparation. Practically speaking, this means clearing my schedule of such clutter as child-rearing and housekeeping, along with dispatching my wife to the store minutes before my friends arrive to procure a second-chin’s worth of kettle chips and a potomaniac’s quantity of cheap beer. Then I settle into the butt-dented comfort of my overworked couch, where I’m surrounded by a rowdy pack of friends.

During hour three of the pre-game analysis, I can’t help but notice that my lovely wife, neither a fan of football or my friends spilling beer on her couch, has contracted a nasty case of the angry stink-eye, which she wields like a laser beam through my skull. I ponder the cost that all of this revelry, last-minute dispatching, and spilled beer will have on my marriage. Concluding that I indeed have at least three paws in the doghouse, I reflect on the facts that a) my wife is a saint; b) she reads this column—honey, read point “a” again; and c) Valentine’s Day is right around the corner.

Oh, well. The game must go on, and right now, it’s all about the NFL—hard-hitting, back-and-forth, in-your-face, smash-mouth action. Unbeatable. Unbeatable, that is, until you realize that a typical football game contains a lot of things, except for much actual football.

The Facts on Football

A recent Wall Street Journal analysis of NFL playoff games reported that the typical football game consists of many things, but not much real action. In fact, the average three-plus-hour telecast consists of just 10 minutes and 43 seconds of play. After subtracting about an hour of commercials, the rest of an average telecast consists of such things as players standing around (67 minutes), replays (17 minutes), and, of course, the all-important shots of cheerleaders—which is allotted, remarkably, only three seconds per game. Seems like more.

In percentage terms, the pie is doled out this way: standing around (58.5%), replays (14.5%), playing time (9.4%), coach shots (4.9%), sideline player shots (3.4%), referee shots (2.4%), crowd shots (0.9%), and other miscellany, such as footage of owners in their high-priced luxury suites (0.3%), the kicker warming up (0.2%), and, of course, cheerleaders (0.1%).

While this level of inaction has an enabling effect on convivial taunting, bet-brokering, and beer runs, it is, to be frank, a laughably low amount of action. How can an entire industry be built on such a level of inactivity? It’s a great question—one that induces a momentary chuckle until I consider how I spend much of my clinical days.

Inactivity in the Workplace

A 2006 paper in the Journal of Hospital Medicine tackled the issue of hospitalist workflow.1 Researchers followed 10 academic hospitalists through various parts of a routine day, all the while measuring to the minute how they spent their time. What they found would be as astounding to hospital outsiders as the NFL data, should anyone ever find themselves so deep in the boredom pit to be watching a hospitalist make rounds.

Which made me wonder: What would Brett Favre, the Minnesota Vikings’ future Hall of Fame quarterback, think if he were watching me ply my trade? Which led me to further wonder how far afield Brett Favre’s life would have to be derailed for him to watch me round. Finally, it left me wondering why I don’t spend my time wondering about more productive things.

Anyway, if Brett were to watch one of us, this is what he’d see: The average hospitalist in this study spent only 18% of their time in direct-patient-care activities, including taking a patient history, examining a patient, and meeting with a patient’s family. Eighteen percent! Isn’t seeing patients why I became a doctor?

While it’s more time than Brett Favre spends slinging the pigskin, it’s still an astonishingly low amount of time actually working with patients. Then there’s the “indirect patient care” category (e.g., reviewing tests, writing notes, making orders), where we spend 69% of our day. This is our time in the huddle, so to speak: lots of planning, little action. Further, these academic hospitalists spent 4% of their time on personal activities (e.g., lunch, bathroom breaks), and 3% of their time in each of the following endeavors: professional development (learning, conferences), teaching, and traveling from floor to floor seeing patients.

Another revealing find was that the average hospitalist spent 6% of their time paging other physicians and 7% returning pages from others (the average hospitalist received 3.4 pages an hour). That’s 13% of the day spent on the phone, or waiting for a phone to ring. That’s about 1.5 hours of a typical 12-hour shift. Over the course of a year, that equates to about 300 hours of time (25 shifts) spent in the paging process. If we could find a way to totally remove the paging process from hospital communication, the average hospitalist could accomplish the same amount of work they do now, and take an additional 20-25 days off per year. Perhaps we should wear high-tech helmets—you know, the kind quarterbacks like Brett Favre use to communicate with his coaches on the sidelines.

Efficient Solutions

Before my hospitalists hit me up for wireless communication devices and an extra three weeks of vacation, understand that much of the paging downtime likely is used for multitasking. In fact, in the study, 21% of a hospitalist’s time was spent working on more than one endeavor. Still, my experience tells me that there is a lot of time lost in the paging vortex.

Furthermore, the 3% of time hospitalists spent walking to other floors, 5% spent on discharge paperwork, and 1% of time spent on routine clerical work (did the researchers inadvertently report 1% instead of 10%?) adds up to nearly a tenth of the day that is either wasted, could be automated, or could be completed by ancillary staff.

To be clear, this happens through no fault of individual hospitalists. Rather, it results from the inefficiency of hospital care systems. And if we endeavor to enhance the revenue, efficiency, and satisfaction of our providers, we need to re-engineer our systems to alter that vast expanse of time spent on inactivity and inefficiency. This means adopting new modes of communication, moving toward geographic rounds, and generally retooling our operational inefficiencies.

Short of that, we risk becoming as idle as the NFL—without the cheerleaders. TH

Dr. Glasheen is The Hospitalist’s physician editor.

Reference

1. O’Leary KJ, Liebovitz DM, Baker DW. How hospitalists spend their time: insights on efficiency and safety. J Hosp Med. 2006;1(2):88-93.

O K, I’ll admit it: I like football. Call me a Neanderthal, but there is nothing quite like an afternoon with friends watching a tightly contested game of titans battling it out on the gridiron. Back in January, I enjoyed that glorious weekend in which the NFC and AFC crown their respective champions, each sending a team of combatants to the Super Bowl.

Fully enjoying the Sunday afternoon of ambrosia requires tons of preparation. Practically speaking, this means clearing my schedule of such clutter as child-rearing and housekeeping, along with dispatching my wife to the store minutes before my friends arrive to procure a second-chin’s worth of kettle chips and a potomaniac’s quantity of cheap beer. Then I settle into the butt-dented comfort of my overworked couch, where I’m surrounded by a rowdy pack of friends.

During hour three of the pre-game analysis, I can’t help but notice that my lovely wife, neither a fan of football or my friends spilling beer on her couch, has contracted a nasty case of the angry stink-eye, which she wields like a laser beam through my skull. I ponder the cost that all of this revelry, last-minute dispatching, and spilled beer will have on my marriage. Concluding that I indeed have at least three paws in the doghouse, I reflect on the facts that a) my wife is a saint; b) she reads this column—honey, read point “a” again; and c) Valentine’s Day is right around the corner.

Oh, well. The game must go on, and right now, it’s all about the NFL—hard-hitting, back-and-forth, in-your-face, smash-mouth action. Unbeatable. Unbeatable, that is, until you realize that a typical football game contains a lot of things, except for much actual football.

The Facts on Football

A recent Wall Street Journal analysis of NFL playoff games reported that the typical football game consists of many things, but not much real action. In fact, the average three-plus-hour telecast consists of just 10 minutes and 43 seconds of play. After subtracting about an hour of commercials, the rest of an average telecast consists of such things as players standing around (67 minutes), replays (17 minutes), and, of course, the all-important shots of cheerleaders—which is allotted, remarkably, only three seconds per game. Seems like more.

In percentage terms, the pie is doled out this way: standing around (58.5%), replays (14.5%), playing time (9.4%), coach shots (4.9%), sideline player shots (3.4%), referee shots (2.4%), crowd shots (0.9%), and other miscellany, such as footage of owners in their high-priced luxury suites (0.3%), the kicker warming up (0.2%), and, of course, cheerleaders (0.1%).

While this level of inaction has an enabling effect on convivial taunting, bet-brokering, and beer runs, it is, to be frank, a laughably low amount of action. How can an entire industry be built on such a level of inactivity? It’s a great question—one that induces a momentary chuckle until I consider how I spend much of my clinical days.

Inactivity in the Workplace

A 2006 paper in the Journal of Hospital Medicine tackled the issue of hospitalist workflow.1 Researchers followed 10 academic hospitalists through various parts of a routine day, all the while measuring to the minute how they spent their time. What they found would be as astounding to hospital outsiders as the NFL data, should anyone ever find themselves so deep in the boredom pit to be watching a hospitalist make rounds.

Which made me wonder: What would Brett Favre, the Minnesota Vikings’ future Hall of Fame quarterback, think if he were watching me ply my trade? Which led me to further wonder how far afield Brett Favre’s life would have to be derailed for him to watch me round. Finally, it left me wondering why I don’t spend my time wondering about more productive things.

Anyway, if Brett were to watch one of us, this is what he’d see: The average hospitalist in this study spent only 18% of their time in direct-patient-care activities, including taking a patient history, examining a patient, and meeting with a patient’s family. Eighteen percent! Isn’t seeing patients why I became a doctor?

While it’s more time than Brett Favre spends slinging the pigskin, it’s still an astonishingly low amount of time actually working with patients. Then there’s the “indirect patient care” category (e.g., reviewing tests, writing notes, making orders), where we spend 69% of our day. This is our time in the huddle, so to speak: lots of planning, little action. Further, these academic hospitalists spent 4% of their time on personal activities (e.g., lunch, bathroom breaks), and 3% of their time in each of the following endeavors: professional development (learning, conferences), teaching, and traveling from floor to floor seeing patients.

Another revealing find was that the average hospitalist spent 6% of their time paging other physicians and 7% returning pages from others (the average hospitalist received 3.4 pages an hour). That’s 13% of the day spent on the phone, or waiting for a phone to ring. That’s about 1.5 hours of a typical 12-hour shift. Over the course of a year, that equates to about 300 hours of time (25 shifts) spent in the paging process. If we could find a way to totally remove the paging process from hospital communication, the average hospitalist could accomplish the same amount of work they do now, and take an additional 20-25 days off per year. Perhaps we should wear high-tech helmets—you know, the kind quarterbacks like Brett Favre use to communicate with his coaches on the sidelines.

Efficient Solutions

Before my hospitalists hit me up for wireless communication devices and an extra three weeks of vacation, understand that much of the paging downtime likely is used for multitasking. In fact, in the study, 21% of a hospitalist’s time was spent working on more than one endeavor. Still, my experience tells me that there is a lot of time lost in the paging vortex.

Furthermore, the 3% of time hospitalists spent walking to other floors, 5% spent on discharge paperwork, and 1% of time spent on routine clerical work (did the researchers inadvertently report 1% instead of 10%?) adds up to nearly a tenth of the day that is either wasted, could be automated, or could be completed by ancillary staff.

To be clear, this happens through no fault of individual hospitalists. Rather, it results from the inefficiency of hospital care systems. And if we endeavor to enhance the revenue, efficiency, and satisfaction of our providers, we need to re-engineer our systems to alter that vast expanse of time spent on inactivity and inefficiency. This means adopting new modes of communication, moving toward geographic rounds, and generally retooling our operational inefficiencies.

Short of that, we risk becoming as idle as the NFL—without the cheerleaders. TH

Dr. Glasheen is The Hospitalist’s physician editor.

Reference

1. O’Leary KJ, Liebovitz DM, Baker DW. How hospitalists spend their time: insights on efficiency and safety. J Hosp Med. 2006;1(2):88-93.