American College of Physicians: Internal Medicine — Doctors for Adults ®


Hospital medicine update

New trends in compensation, training will affect internists

By Linda Gundersen

The reimbursement spotlight is shifting to pay-for-performance, and this year's moderators for the hospital medicine update will discuss its impact on physicians. Alpesh Amin, FACP, and Michael J. Pistoria, FACP, will also talk about 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.


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, and co-moderator Dr. Pistoria, 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., will cite an article in Annals of Internal Medicine by Rowe (2006;145:695-699), which provides details on this trend. Dr. Amin said, "This is going to impact everyone—especially internists, as they are large-volume providers of health care."

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.

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 patients undergoing hip fracture surgery. In addition, median cost was $1,777 less in the hospitalist group than in the nonhospitalist group. Drs. Amin and Pistoria will discuss the retrospective study, which looked at 118 cases. 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. "By implementing a good program, you could significantly reduce length of stay and improve outcomes, save dollars—and save patients," Dr. Amin said. He and Dr. Pistoria will discuss the program's parameters in additional detail at the update.

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 defined as severe. When patients were switched from IV to oral antibiotics, they could be safely discharged without complications. "We've got better antibiotics with better bioavailability these days than we had in the past," Dr. Amin pointed out, adding that keeping patients in the hospital for 24 hours after switching to oral antibiotics is no longer necessary.

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. "If you have a very low risk of suspicion for DVT, and you do a D-dimer test, you can probably exclude DVT without getting an ultrasound on your patient," Dr. Amin said. He added that the key is to carefully assess patients for low-risk status using clinical prediction rules, a process that has been validated in clinical studies and that can accurately categorize patients as being at low, moderate or high risk. According to this model, patients with low clinical probability had a DVT prevalence of less than 5%.

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. "Everyone was very gung ho to apply the data from surgical patients to all other patients, but this study shows we need to understand that the populations are different in surgical and in medical patients," Dr. Amin said.

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