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Hospital medicine update

New trends in compensation, training will affect internists

From the June ACP Hospitalist, copyright © 2007 by the American College of Physicians.

By Linda Gundersen

The reimbursement spotlight is shifting to pay-for-performance, and this year's moderators for the update in hospital medicine at Internal Medicine 2007 in San Diego discussed its impact on physicians. Alpesh Amin, FACP, and Michael J. Pistoria, FACP, also spoke about literature on new approaches in training internists and the impact of a hospitalist model of care, as well as important findings on bloodstream infections in the intensive care unit (ICU), intravenous (IV) versus oral antibiotics, deep venous thrombosis (DVT) and insulin therapy.

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Alpesh Amin, FACP

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Pay-for-performance

Although the concept of pay-for-performance is still being debated in the health care field, CMS is moving to adopt this structure for Medicare beneficiaries. CMS is planning to offer physicians incentives to achieve the highest quality of care, but specific criteria for pay-for-performance are still being defined. Physicians can expect health insurance companies to fall in line with the implementation in the future.

With employers demanding more bang for their health care buck, some experts believe pay-for-performance can help improve the quality of health care in the U.S. Dr. Amin, who is professor and chief of general internal medicine and executive director of the hospitalist program at University of California, Irvine, cited an article in Annals of Internal Medicine by Rowe (2006;145:695-699), which provided details on this trend. The article cited five major factors that need to be taken in to account when pay-for-performance programs are designed:

1. Clinical practice;
2. Target of the incentive;
3. Form of the incentive;
4. Cash incentives; and
5. Development of standards of performance

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Michael J. Pistoria, FACP

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"This could be a measure of success for hospitalists," Dr. Amin said. "One of the things that we want to do as hospitalists is improve the systems that we work in."

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Internist training

Training for internists could undergo radical changes. A position paper by Fitzgibbons and colleagues, published in Annals of Internal Medicine (2006;144:920-926), looked at trends in internal medicine and found significant shifts in recent years, mainly the focus on specialization, increased pressure on time management and the hospitalist movement.

"These trends raise the question of whether the training of future internists needs to change accordingly," Dr. Amin said. The position paper was issued by the Association of Program Directors in Internal Medicine and strongly advocated redesigning residency education.

Numerous other models suggest various approaches to residency reform, all of which will impact how future internists would be trained. For example, some experts suggest that physicians undergo two years of training in internal medicine with the third year focusing on specialization, rather than three years of internal medicine training.

"Hospitalists are uniquely positioned to help facilitate medical education redesign, at least for the inpatient arena, and should take the lead," Dr. Amin said.

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Hospitalist care

Using a hospitalist might shave one day off the hospital stay of a patient with hip fracture. This was the finding in an article by Roy and other investigators in Mayo Clinic Proceedings (2006;81:28-31), which looked at the relationship between the hospitalist–consultant model of care and length of stay and the overall hospital cost in 118 patients undergoing hip fracture surgery. In addition, median cost was $1,777 less in the hospitalist group than in the nonhospitalist group. While patients were still attended by their orthopedic surgeon, patients in the hospitalist group were discharged one day sooner than those in the nonhospitalist group.

Catheter-related infections

Bloodstream infections in the ICU are common, costly and potentially fatal, but a recent study by Pronovost and colleagues outlined an intervention with promising results. The study, published in the New England Journal of Medicine (2006;355:2725-32), involved 108 participating ICUs that implemented a program from the CDC. Incidences of catheter-related infections were reduced, and catheter-days decreased from 7.7 to 1.4. Data indicate that the cost per patient with this infection is $45,000, with annual costs topping out at $3.3 billion. Dr. Amin pointed out that implementing this type of program could significantly reduce length of stay, improve outcomes and control costs.

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IV vs. oral antibiotics

An early switch from intravenous to oral antibiotics in patients with community-acquired pneumonia showed a two-day reduction in length of stay per patient, according to an article in the British Medical Journal by Oosterheert and associates (2006;333:1193). The randomized trial involved 302 patients at five teaching hospitals and two university medical centers who were on the medical/surgical floor, not in intensive care, and had community-acquired pneumonia (CAP) defined as severe. When patients were switched from IV to oral antibiotics, they could be safely discharged without complications.

"It looks like [IV to oral conversion in severe CAP] is safe, it looks like it decreases length of stay by two days, and that's a significant opportunity for us as hospitalists," Dr. Amin said.

Deep venous thrombosis

The process of diagnosing DVT just got one step shorter: A study in JAMA by Wells and colleagues (2006;295:199-207) suggests that ultrasound is unnecessary in diagnosing DVT, given the right conditions. According to this model, patients with low clinical probability had a DVT prevalence of less than 5%.

"If you have the combination of low clinical probability and negative D-dimer testing, you can stop. Don't pass go, don't collect $200; you're done," said Dr. Pistoria, who is chief of the division of hospital medicine at Lehigh Valley Hospital in Allentown, Pa., and assistant professor of medicine at Penn State College of Medicine in Hershey, Pa. Physicians should proceed to further evaluation in patients with high clinical probability, a positive D-dimer or both and in patients with intermediate probability of DVT, Dr. Pistoria said.

He added that this study offers a research opportunity for hospitalists to validate these rules in hospitalized patients, as well as an opportunity to partner with other doctors across the continuum of care to streamline DVT diagnosis.

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Intensive insulin therapy

It is now known that intensive insulin therapy can reduce morbidity and mortality in surgical ICU patients, but can this data be generalized to apply to medical ICU patients? Van den Berghe and colleagues reported a randomized, controlled trial in the New England Journal of Medicine (2006;354:449-461) that showed a reduction in morbidity, but not mortality, in 1,200 adult medical ICU patients. Patients' blood glucose was controlled to levels between 180 mg/dL and 110 mg/dL. There was a reduction of risk in both mortality and morbidity in patients treated for three or more days—but so far, there is no good way to predict which patients would be in the ICU for that long. Dr. Pistoria pointed out that the study raised several important questions, such as the timing of intensive insulin therapy and why patients who were treated for less than three days actually fared worse.

"It's clear that [ICU insulin protocols] do work to some extent," Dr. Pistoria said, "just not as well, at least initially, as we thought."

Linda Gundersen is a freelance writer in Perkasie, Pa.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated