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ACP HospitalistWeekly

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In the News for the Week of 2-1-12

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Highlights

Hospitalist practice models have little effect on job satisfaction, burnout, survey finds

Job satisfaction and burnout rates are similar across different hospitalist practice models, a recent survey found. More...

Hospital stays involving C. diff leveled off between 2008 and 2009

Hospital stays involving Clostridium difficile infections leveled off between 2008 and 2009 after rising 300% between 1993 and 2008, the Agency for Healthcare Research and Quality (AHRQ) reported. More...

Cardiology

Sexual activity safe for most CVD patients

It is reasonable for most patients with cardiovascular disease (CVD) to engage in sexual activity, according to a new scientific statement from the American Heart Association. More...

Drug shortages

Propofol shortage did not affect mechanical ventilation duration at one center, study finds

A nationwide propofol shortage did not affect duration of mechanical ventilation at a single U.S. academic medical center, a recent study showed. More...

Medicare

Most Medicare demos fail to reduce costs

The Congressional Budget Office (CBO) has analyzed recent Medicare demonstration projects and concluded that most have not reduced costs, but those that did had certain specific characteristics. More...

Cartoon caption contest

Put words in our mouth

ACP HospitalistWeekly wants readers to create captions for our new cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service. More...

Physician editor: A. Scott Keller, MD, FACP

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Highlights

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Hospitalist practice models have little effect on job satisfaction, burnout, survey finds

Job satisfaction and burnout rates are similar across different hospitalist practice models, a recent survey found.

Researchers administered the survey to a randomized, stratified sample of 3,767 potential hospitalists, 662 of whom were members of three multistate hospitalist companies. The survey used a five-point Likert scale to address hospitalist group characteristics, work patterns, demographic information, global job satisfaction and 11 satisfaction domains including compensation, autonomy, personal time, care quality and organizational fairness. They examined relationships between global satisfaction and satisfaction domains, and burnout symptoms and career longevity. Results were published online Jan. 23 in the Journal of Hospital Medicine and in the January Journal of General Internal Medicine.

A total of 794 responses were included in the analysis. Among respondents, 44% were directly employed by a hospital, 15% by a multispecialty physician group, 14% by a multistate hospitalist group, 14% by a university or medical school, 12% by a local hospitalist group and 2% by "other." Reported findings included the following:

• Hospitalists with local groups had more clinical shifts per month (19 shifts for local groups vs. 17 for multistate groups, 15 for multispecialty groups and academics, 16 for hospital-employed);
• Hospitalists with local and multistate groups had more billable encounters per shift (17 encounters for each vs. 15 for hospital-employed, 14 for multispecialty groups, 13 for academics);
• Academic hospitalists had fewer night shifts (14% of shifts vs. 23% each for multistate and multispecialty groups), more nonclinical work hours per month (71 hours vs. 19 for multistate groups) and lower earnings ($166,478 on average vs. $226,065 for local groups);
• Academic hospitalists were least likely to participate in comanagement (71% vs. 100% with local groups), intensive care unit (ICU) care (27% vs. 94% with multistate groups) and nursing home care (8% vs. 30% with local groups);
• 11% to 19% of time was spent on administrative and committee work, with the least amount spent by hospitalists in multistate groups and the most by academic hospitalists;
• A majority of respondents (62%) had high satisfaction ratings (≥4 on a 5-point scale);
• Job burnout symptoms were reported by 30% of respondents, who were more likely to leave their jobs or reduce work effort;
• The greatest satisfaction was with the quality of care provided and relationships with staff and colleagues; and
• The least satisfaction was with organizational climate, autonomy, compensation, and availability of personal time.

While there were differences among the practice models in clinical and nonclinical responsibilities, and in factors most important to job satisfaction, the levels of job satisfaction and burnout were similar, the researchers noted in the JHM article. The finding suggests "individuals find settings that allow them to address their individual professional goals," they wrote. They also noted a growth in the number of hospitalists who participate in ICU care and co-management as proof that "collaborative care (is) one of the dominant drivers of the hospitalist movement." Finally, they noted that compensation and workload are not the only factors that contribute to job satisfaction, and advised administrators to adopt "more nuanced approaches" to recruiting and retaining hospitalists than simply focusing on salary and workload.

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Hospital stays involving C. diff leveled off between 2008 and 2009

Hospital stays involving Clostridium difficile infections leveled off between 2008 and 2009 after rising 300% between 1993 and 2008, the Agency for Healthcare Research and Quality (AHRQ) reported.

There were 336,600 hospitalizations (about 1% of all hospital stays) involving C. diff. in 2009, with nearly one-third of these cases having C. diff. as the principal diagnosis. By contrast, 349,000 hospital stays involved C. diff. in 2008, and 86,000 hospital stays involved the infection in 1993.

Dehydration and electrolyte disorders were the most common conditions associated with C. diff. infection (CDI) stays; they were seen in 81.2% of stays. Other common, associated conditions were septicemia (26.7%), renal failure (23.6%), septic shock (8.0%) and prolonged ileus (4.7%). Septic shock was eight times more common in secondary diagnosis CDI stays than in principal diagnosis stays (11.3% vs. 1.4%). Patients with CDI hospitalizations were more severely ill than hospitalized patients in general, with 9.1% of stays ending in death compared with less than 2% of other inpatients.

Patients with CDI spent an average of 13 days in the hospital, more than eight days longer than the average hospital stay for other inpatients. CDI patients were nearly 20 years older than other inpatients, and were more likely to be covered by Medicare, be female, live in the Northeast, and have an income greater than $50,000 per year, the AHRQ brief said.

Cardiology

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Sexual activity safe for most CVD patients

It is reasonable for most patients with cardiovascular disease (CVD) to engage in sexual activity, according to a new scientific statement from the American Heart Association.

A multidisciplinary group of experts developed the evidence-based statement to synthesize and summarize existing data into recommendations and foster communication between clinicians and patients about sexual activity. The statement specifically addresses several different conditions, including coronary artery disease, heart failure, valvular heart disease and arrhythmias.

In general, the experts concluded that sexual activity is reasonable for patients who, on clinical evaluation, are at low risk of cardiovascular complications (Class IIa, Level of Evidence B recommendation). Any patients with unstable or severe symptoms should be stabilized before sexual activity (III, C). To determine which category a patient falls into, a comprehensive history and physical is reasonable before a physician provides a recommendation (IIa, C). If a patient's risk is uncertain after examination, exercise testing can be useful (IIa, C).

Cardiovascular drugs that can improve symptoms and survival should not be withheld because of concerns about sexual function, the statement said (III, C). Recent data do not show clear relationships between most of these drugs and erectile dysfunction. For patients who do have sexual dysfunction and stable CVD, PDE5 inhibitors can be useful (I, A). However, PDE5 inhibitors are absolutely contraindicated in patients taking nitrates (III, B).

Physicians should assess anxiety and depression regarding sexual activity in their CVD patients, the statement recommended (I, B). They should also counsel both the patient and spouse or partner about sexual activity following an acute cardiac event, new CVD diagnosis or ICD implantation (I, B). Suggestions to the patient for making activity safer could include "being well rested at the time of sexual activity, avoiding unfamiliar surroundings and partners to minimize stress during sexual activity, avoiding heavy meals or alcohol before sexual activity, and using a position that does not restrict respiration."

The statement was also endorsed by the American Urological Association, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association of Cardiovascular and Pulmonary Rehabilitation, International Society of Sexual Medicine, American College of Cardiology Foundation, Heart Rhythm Society, and Heart Failure Society of America. It was published online by Circulation on Jan. 19.

Drug shortages

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Propofol shortage did not affect mechanical ventilation duration at one center, study finds

A nationwide propofol shortage did not affect duration of mechanical ventilation at a single U.S. academic medical center, a recent study showed.

Researchers at Tufts Medical Center in Boston performed a before-after study in three noncardiac-surgery adult ICUs to determine whether patients spent less time on mechanical ventilation before the propofol shortage (Dec. 1, 2008 to May 31, 2009) than after (Dec. 1, 2009 to May 31, 2010). The study examined 281 consecutive patients who received mechanical ventilation for at least 48 hours, were given a continuous sedative infusion for at least 24 hours, and were then successfully extubated and discharged from the ICU. Results were published in the February Critical Care Medicine.

One hundred twenty-eight patients were ventilated after the propofol shortage, and 153 were ventilated before. Patients in the after group were younger, had a higher Acute Physiology and Chronic Health Evaluation II score at admission, and were more likely to have acute alcohol withdrawal and primarily receive pressure-controlled ventilation. Continuous infusion of propofol for at least 24 hours was much more common before the shortage than after (94% vs. 15%; P<0.0001), and patients who were mechanically ventilated after the shortage were more likely to receive continuous infusions of lorazepam (15% vs. 7%; P=0.037) and midazolam (81% vs. 30%; P<0.0001). In unadjusted analyses, the median duration of ventilation was 6.7 days before the shortage and 9.6 days after the shortage (P=0.02). However, in a regression model, duration of mechanical ventilation was affected by Acute Physiology and Chronic Health Evaluation II score (P<0.0001), medical service admission (P=0.009), and pressure-controlled ventilation (P=0.02), but not by propofol use (P=0.35).

The authors could not conclude definitively that the propofol shortage had no effect on mechanical ventilation duration, although they noted that such an effect, if present, was probably very small. Data on weaning efforts and the proportion of patients with delirium were not available, and the study did not include safety-related outcomes, among other limitations. However, the authors concluded that although propofol use at Tufts Medical Center's ICUs decreased dramatically during the nationwide shortage, lack of the drug did not appear to affect duration of mechanical ventilation. Additional research is needed, they said, on the reasons behind ICU drug shortages, legislation to address the issue, and the impact of such shortages on patient outcomes.

Meanwhile, an article published online Jan. 19 by Clinical Infectious Diseases examined shortages of anti-infective drugs in the U.S. The authors found that such shortages are common and can have a substantial impact on patient care because anti-infectives are often the only treatments available for particular conditions. In addition, multidrug resistance has increased and fewer new anti-infective agents have been approved by the FDA in recent years. "These factors have converged to create a public health emergency," the authors wrote.

Shortages can be due to manufacturing problems, business decisions to halt drug production, stockpiling, inferior inventory practices, or changed indications for drugs, among other factors. The authors pointed out that manufacturers are not required to explain why a drug is in short supply, which limits the information available on causes. They called for increased federal authority to manage such shortages, beginning with proposed amendments to the Food, Drug and Cosmetic Act. "Enhanced oversight by governmental agencies may be necessary to identify and correct shortages of these life-saving anti-infectives," they concluded.

Medicare

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Most Medicare demos fail to reduce costs

The Congressional Budget Office (CBO) has analyzed recent Medicare demonstration projects and concluded that most have not reduced costs, but those that did had certain specific characteristics.

The CBO issue brief reviewed 10 projects, six that focused on disease management and care coordination and four that were value-based payment demonstrations. All of the care coordination projects used nurses as care managers and sought to reduce hospital admissions. On average, the programs achieved little or no reduction in admissions, but the effects of the programs varied considerably. Some programs reduced admissions by 15% or more, while in others admissions rose by at least 15%.

In most of the care coordination programs, the care manager was not integrated into the physician's office and had only telephone contact with patients. The CBO analysis found that these two design elements were associated with the results of the programs; care coordinators who interacted more closely with physicians and patients were more likely to reduce admissions. However, even these more successful programs did not, for the most part, achieve enough savings to offset the fees they were paid for the demonstration. Whether the practice's fees were at risk in the demonstration did not appear to affect the success or failure of a program.

The four value-based demonstration programs in the analysis were the Physician Group Practice Demonstration, the Premier Hospital Quality Incentive Demonstration, the Medicare Participating Heart Bypass Center Demonstration and the Home Health Pay-for-Performance Demonstration. Only the bypass demonstration yielded significant savings for Medicare, reducing expenditures for bypass surgery by about 10%. The bypass demonstration was the only one of the four that used a bundled payment system to reduce costs. Participating hospitals and physicians were motivated to accept a discounted, bundled payment for their services due to competitive pressures in their markets, the CBO brief noted.

These findings suggest that substantial changes to payment and delivery systems will probably be required before demonstrations like these can significantly reduce spending or improve care, the brief concluded. The author also cited several other lessons to be taken from these demonstrations, including the need to gather timely data, focus on transitions of care, use team-based care, target high-risk patients, and limit the fees paid to participating organizations.

Cartoon caption contest

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Put words in our mouth

ACP HospitalistWeekly wants readers to create captions for this cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.

E‑mail all entries to acphospitalist@acponline.org. ACP staff will choose finalists and post them online for an online vote by readers. The winner will appear in an upcoming edition.

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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