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Step-by-Step Medicine

From: The Hospitalist, January 2010

Oft-debated consensus practice guidelines, essential to healthcare reform, gain traction

by Christopher Guadagnino, PhD

Evidence-based practice guidelines are key tools to help hospitalists practice high-quality medicine and demonstrate the value of their inpatient care model. Guidelines are designed to produce superior care outcomes and resource utilization efficiencies by encouraging proven medical practices and discouraging ineffective or unproven ones. Yet inefficiencies, variation, and quality gaps persist in medical care—much to the chagrin of policymakers.

Is the answer more guidelines, and better implementation of existing ones?

Research experts and many HM leaders say yes.

In fact, HM is leading the way in an important new area for which there is little uniform guidance: optimal care transitions during patient handoffs. Care transitions are a pivotal time in the patient care process and are replete with avoidable service duplication, poor communication among providers, gaps in care reconciliation, and patient-safety issues.

SHM has joined five other organizations in issuing a Transitions of Care Consensus Policy Statement, which promises more systematic, safe, and efficient patient handoffs.1 SHM also is targeting care-transition improvement in a variety of other venues, all of which can help hospitalists demonstrate more persuasively the value they bring to healthcare delivery.

Guidelines Work

Practice guidelines work, in the sense that they help providers practice in ways consistent with what the best aggregate knowledge and expert opinion says is most effective. The evidence allows physicians to avoid expending scarce resources on ineffective clinical services. Their importance is magnified by the current urgency given to value-based purchasing in healthcare reform. “The right care, for the right patient, at the right time” is the new mantra of payors and policymakers, many of whom are demanding the best and most efficient healthcare delivery at the lowest cost.

Roberta Fruth, PhD, RN, FAAN, JCR/JCIListen to Roberta Fruth, PhD, RN, FAAN, JCR/JCI, senior consultant for Joint Commission Resources, and Janet Corrigan, PhD, MBA, president and CEO of the National Quality Forum, discuss evidence-based practice guidelines.

“When providers are not providing the right care at the right time to patients, we find that the patient often gets more services … that they didn’t need. That oftentimes exposes them to potential harm and (services) that are wasteful of resources,” says Janet M. Corrigan, PhD, MBA, president and CEO of the National Quality Forum (NQF), a standard-setting organization that convenes national experts to apply “gold standard” endorsement of guidelines developed by professional medical societies and other entities. “Guidelines are a way of synthesizing evidence and translating it into action steps that providers can follow so that they get the best results that we know how to get for their patients.”

Clinicians and healthcare organizations have several sources for guidelines. The Agency for Healthcare Research and Quality (AHRQ) systematically reviews and vets guidelines submitted for inclusion in its National Guideline Clearinghouse (www.guideline.gov), and makes them available for evidence-based clinical decision-making, says Jean Slutsky, director of AHRQ’s Center for Outcomes and Evidence. AHRQ also offers public access to the National Quality Measure Clearinghouse and the Health Care Innovations Exchange, repositories of searchable quality measures and tools relevant to an array of diseases and conditions.

Figure 1. Applying Classification of Recommendations and Level of Evidence
click for large version
Figure 1. Applying Classification of Recommendations and Level of Evidence

The Institute for Healthcare Improvement (IHI), an independent nonprofit organization, helps frontline physicians implement guidelines, and also helps provider teams decide which guidelines are most appropriate to achieve their desired outcomes, according to Amy E. Boutwell, MD, MPP, IHI’s director of health policy strategy.

Hospitalists use an array of disease-specific practice guidelines from different specialty societies for diagnoses they frequently encounter, such as chest pain, stroke, pneumonia, myocardial infarction, gastrointestinal bleeding, asthma, and chronic obstructive pulmonary disease (COPD). “Most hospitalists want to keep up with the best available evidence,” says Patrick J. Torcson, MD, MMM, FACP, director of hospital medicine at St. Tammany Parish Hospital in Covington, La., and chair of SHM’s Performance and Standards Committee. “The recently updated American College of Cardiology (ACC) and American Heart Association (AHA) guidelines on heart failure are exceptional. The American College of Chest Physicians has an extremely comprehensive set of guidelines on thrombosis, which is the bible for handling anticoagulation.”

Studies are published every month demonstrating that physicians who implement national guidelines at the local level improve such patient outcomes as mortality, length of stay, and time to clinical stability. Dr. Corrigan notes that there are abundant examples of guideline adherence boosting quality outcomes, and cites as a prime example the AHA’s Get With the Guidelines program (www.american heart.org/presenter.jhtml?identifier=1165), which has documented quality gains in coronary artery disease, stroke, and heart failure patients.

William T. Ford, MD, FHMWe’re finally shedding light on how to tackle patient handoff and hospital readmission issues. ... If we were to solve just that one piece, we can more easily start implementing other clinical guidelines.
—William T. Ford, MD, FHM, section chief of hospital medicine, Temple University Hospital, Philadelphia

Barriers to Acceptance and Adherence

But there are obstacles to guideline adherence, and widespread practice pattern variation remains a huge national problem. Providers in some regions of the country can use twice the resources as their counterparts in other regions and bring no additional benefit to patients (see “Medicare Fee Inspection,” p. 30). The Dartmouth Atlas of Health Care says unwarranted practice variation is responsible for as much as 30% of wasted healthcare spending in the U.S.—a cost that reformers are anxious to eliminate.

The traditional culture of autonomy in the medical profession is perhaps the most difficult and enduring barrier to reducing unjustified practice variation: clinicians don’t automatically follow guidelines, many treat them more as options than as true standards, and organizations do not sufficiently enforce or reward adherence to guidelines, wrote researchers in a special 2005 issue of Health Affairs focusing on guidelines.2

Care-Transition

Physicians and hospitals can get expert guidance implementing care-transition guidelines. Here are some of the best resources:

  • Joint Commission Resources (JCR), the educational consulting arm of The Joint Commission, helps organizations assess how they are meeting such core accreditation measures as educating patients about their medication and care plan upon discharge, says Roberta Fruth, PhD, RN, FAAN, JCR/JCI, senior consultant for JCR. In one hospital, for example, implementing patient discharge education checklists and assigning accountability to specific staff members greatly improved discharge-planning performance. “Hospitalists have been leading many workflow improvement projects like these,” Dr. Fruth says.
  • The Joint Commission recently launched its Center for Transforming Healthcare, tasked with identifying and implementing consistent best practices that address quality and safety challenges facing healthcare organizations, and sharing proven solutions with the more than 17,000 organizations it accredits. The center first addressed hand hygiene to prevent the spread of infections, and is focusing on effective handoff communications.
  • SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions) translates consensus guidelines for effective hospital discharge planning into clear, achievable intervention steps that specific institutions can customize and implement. The program offers training sessions, as well as yearlong mentoring programs in which expert coaches provide hands-on facilitation to help hospitals implement best practices for safe and effective discharge of elderly patients from the hospital, says Tina Budnitz, MPH, Project BOOST’s director and SHM senior advisor.

The project aims to reduce 30-day readmission rates, improve information flow between sending and receiving physicians, ensure that high-risk patients receive follow-up calls within 72 hours of discharge, and improve patient and family education practices to encourage use of the teach-back process around risk-specific issues such as medication compliance. SHM is collecting data from the program’s mentoring activities at 30 hospital sites. “We’re meeting with legislators to encourage the adoption of Project BOOST demonstration projects in their healthcare reform bills, as a means to lower preventable hospital readmission rates,” Budnitz says.

  • IHI synthesizes guideline literature and has been working with a number of hospitals over the past two years to advise front-line-care teams how to improve care transitions and lower preventable hospital readmission rates.
  • SHM has launched a series of leadership training programs for its members, focusing on topics including protocol implementation, interdisciplinary team-building, and communication strategies for conflict resolution among clinicians. “Our programs help hospitalists and other clinicians change processes to better prepare their patients to go home, or to strengthen their relationship with primary-care physicians in the community after their patient is discharged,” Budnitz says.
  • SHM is leading the development of care-transition measures for the Physician Consortium for Performance Improvement (PCPI), an AMA-convened organization that is developing performance measures to be used for outcome measurement, quality reporting, and pay-for-performance incentive programs, says Joseph A. Miller, SHM executive advisor to the CEO. The measures could soon be included in Medicare’s Physician Quality Reporting Initiative (PQRI).—CG

“In an age of mandated cost control and resource limitation under managed care,” the researchers wrote, some physicians still regard practice guidelines as “cookbook medicine” that threatens the use of clinical judgment and encourages treating patients as essentially interchangeable. In the face of that perceived threat, the researchers added, many physicians continue to uphold a traditional view of medicine as an art “in which individual expertise and technique are allowed to shine through and ultimately result in a higher standard of patient care.”

Dr. Corrigan acknowledges the significant obstacles to successful practice guideline implementation:

  • Guidelines are developed by various sources, particularly specialty societies, who do not always coordinate their activities. Physicians are left with overlapping and sometimes contradictory guidelines for managing the same disease or condition.
  • Guidelines must be maintained and kept current, or physicians will lose confidence and not follow them.
  • Guidelines are of varying quality. Some provide clear clinical direction; others are not written in a way that physicians can clearly translate into clinical practice.
  • There are significant gaps in the evidence basis for guideline development. Much more comparative effectiveness research needs to be conducted to develop more valid and meaningful guidelines.
  • Guidelines must be communicated effectively to physicians, making them available and convenient at the point of clinical care. Electronic health records with user-friendly decision support functions show great promise in “making the right thing the easy thing to do.”
  • The fee-for-service payment system encourages greater volume of services, irrespective of guideline recommendations.

Physicians also recognize inherent limitations of guidelines. “Guidelines typically apply across populations. Adding levels of clinical complexity gets further away from a guideline’s applicability. Many physicians will tell you that the patient in front of them is a special case requiring a modification of the protocol,” Dr. Boutwell explains. For example, diabetic management guidelines are based on what is best for a population of diabetics, versus what is best for said hospitalist’s patient who has eight co-morbidities, one of which is diabetes, Boutwell notes. “Guidelines come disease-specific. Patients don’t,” she adds.

Nevertheless, Dr. Boutwell notes, there are robust guidelines and the IHI tries to help front-line physicians and care teams to implement them reliably and effectively.

An obstacle that inhibits hospitalists from implementing guidelines in an optimal fashion “is that we’re not one specialty—we deal with it all—and that complexity can be overwhelming. There is no central repository where all of the guidelines can be found in one place,” according to William T. Ford, MD, FHM, program medical director for Cogent Healthcare and section chief of hospital medicine for Temple University Hospital in Philadelphia.

Make Guidelines Work

Researchers say guidelines are most successful when they are well-supported and uncomplicated, backed by strong leadership and sufficient resources, and are used as “rallying points” to stimulate interdependent and collaborative care among physicians, nurses, pharmacists, equipment suppliers, administrators, and patients.

“Guidelines are really the foundation for determining best practices,” Dr. Torcson says. “There is no shortage of excellent guidelines, or proof that specific interventions do improve outcomes. The key is achieving more uniform implementation. We need tools like pre-printed orders in electronic health records (EHR) to effectively integrate these guidelines into hospitalists’ practice.”

More widespread EHR adoption with user-friendly medical decision-support systems will play a huge role in boosting guideline adoption and effectiveness, says Mary Nix, MS, MT(ASCP)SBB, health science administrator at AHRQ and project officer for the agency’s Center for Outcomes and Evidence.

Dr. Ford says HM groups must evaluate the top 10 to 15 diagnosis-related groups (DRGs) that they see each day (e.g., congestive heart failure, acute kidney failure, pneumonia, cellulitis, or acute coronary syndrome) and come to consensus on which guidelines best address them.

HM groups must then secure buy-in to those guidelines from everyone in the group; from the subspecialists they work with; and from their hospital’s chief medical, financial, and utilization officers.

Care-Transition Guidelines: Opportunity for Hospitalists

A particularly important HM opportunity is improving care transitions. Deficits in communication and information transfer between hospital-based and primary-care physicians (PCPs) are “substantial and ubiquitous,” while delays and omissions are consistently large, and traditional methods of completing and delivering discharge summaries are “suboptimal for communicating timely, accurate, and medically important data to the physicians who will be responsible for follow-up care,” according to a hospitalist-authored Feb. 28, 2007, article in the Journal of the American Medical Association.3 PCPs routinely are not notified about patient admissions or complications during the hospital stay, and some PCPs fail to provide sufficient information to hospitalists at admission, fail to visit or call hospitalized patients, or fail to participate in discharge planning, the study’s researchers noted. For patients with chronic illnesses and frequent hospitalization, those deficits are multiplied, making completeness of information handoffs particularly important.

Because patient handoffs have notoriously been fraught with miscommunication and poor information exchange between providers, adopting a professional consensus on what constitutes the best, safest, and most effective activities during these handoffs is sorely needed.

“Care-transition guidelines can have tremendous power because they affect every hospital patient—each of whom experiences care transitions,” says Rusty Holman, MD, FHM, chief operating officer of Brentwood, Tenn.-based Cogent Healthcare and past president of SHM. “It is an area undergoing rapid development, evolution, and discovery, and hospitalists have positioned themselves as leaders and owners of this particular scenario.”

Dr. Holman
Dr. Holman

As care-transition guidelines emerge and mature, Holman thinks they eventually will be tied to value-based healthcare purchasing programs that affect hospitalists’ reimbursement equations and further boost incentives to follow those guidelines. A prime example: Medicare calculated it could save $12 billion annually by reducing preventable 30-day hospital readmissions and will soon stop paying for them. Perhaps 3% to 5% of a hospital’s DRG reimbursement will be at risk under Medicare’s proposal, Dr. Torcson notes.

“Hospitals are going to be much more motivated to build systems and engage physicians, especially hospitalists, to lower readmission rates. Hospitalists will be focusing more and more on how care-transition process improvements can lower those rates,” Dr. Holman says. “That’s a huge opportunity for hospitalists to make a business case for the value they bring to their institutions, and will further justify the financial support they already receive.”

Dr. Ford is more cautious in his appraisal of the financial rewards of better guideline implementation. “We do not capture that much revenue per patient, and even a length-of-stay reduction is difficult for a hospital’s CFO to extrapolate how much money hospitalists save,” he says. “I don’t think hospitalists will be paid more, even if they save the hospital money. You’re just doing your job, but you’re going to keep your job, and you’ll have an enormous bargaining chip when renegotiating contracts with hospitals.”

Still, a prevented readmission might mean a bed for a revenue-generating elective surgery, something that adds to the reward equation.

Patrick Torcson, MD, MMM, FACPGuidelines are the foundation for determining best practices. There is no shortage of excellent guidelines, or proof that specific interventions do improve outcomes. The key is achieving more uniform implemenation.
—Patrick Torcson, MD, MMM, FACP, director of hospital medicine, St. Tammany Parish Hospital, Covington, La., SHM Performance and Standards Committee chair

Transition Evolution

SHM and other sources offer physicians and hospitals expert assistance in implementing care-transition guidelines (see “Care-Transition Guidance,” p. 7). The transitions-of-care policy statement jointly issued by the SHM and five other specialty societies further demonstrates that hospitalists play a key leadership role on this front.1

The policy statement emerged from a multi-stakeholder consensus conference convened by SHM, the American College of Physicians (ACP), and the Society of General Internal Medicine, which was attended by more than 30 medical specialty societies, governmental agencies, and performance measure developers. Participants focused on what standard pieces of information should be exchanged among providers during inpatient to outpatient transitions, and they issued a set of standards for improving those transitions (see “Managing Transitions in Care Between the Inpatient and Outpatient Settings,” p. 7).

“This consensus statement has enormous significance,” Dr. Ford says. “We’re finally shedding light on how to tackle patient handoff and hospital readmission issues, and we as a specialty have to take on care-transition improvement as our mantra. If we were to solve just that one piece, we can more easily start implementing other clinical guidelines. Care-transition guidelines are a fundamental tool to build consensus within your own group and with other clinicians in a team approach.”

Dr. Corrigan applauds the physician groups for publishing the transitions-of-care statement and encourages the societies to work together to “take it to the next step, which is to develop the measures and get them endorsed through the NQF process.”

Join Team Hospitalist

Want to share your unique perspective on hot topics in HM? Team Hospitalist is accepting applications for two-year terms beginning in April. If you are interested in joining our reader-involvement program, e-mail Editor Jason Carris at jcarris@wiley.com.

SHM members are participating in workgroups convened by the NQF to identify standardized performance measures and to develop action plans over the next few months for several national priority areas—one of which is care coordination. “We have a ways to go to achieve better patient handoffs and information exchange between hospitals and other settings in the community. Hospitalists can drive the development of those guidelines and protocols,” Dr. Corrigan says. TH

Christopher Guadagnino, PhD, is a freelance medical writer based in Pennsylvania.

References

  1. Kripalani S, LeFevre F, Phillips CO, Williams MV; Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297:831-841.
  2. Timmermans S, Mauck A. The promises and pitfalls of evidence-based medicine. Health Affairs. 2005; 24(1):18-28.
  3. Snow V, Beck D, Budnitz T, et al. Transitions of care consensus policy statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, Society of Academic Emergency Medicine. J Hosp Med. 2009: 4(6)364-370.

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Managing Transitions of Care Between the Inpatient and Outpatient Settings

Managing Transitions of Care Between the Inpatient and Outpatient Settings
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The following are joint recommendations from SHM, ACP, SGIM, AGS, ACEP, and SAEM, based upon a multi-stakeholder consensus conference in July 2007 and published in the July/August Journal of Hospital Medicine (http://onlinelibrary.wiley.com/doi/10.1002/jhm.510/full):

  1. Communication and information exchange between the sending and receiving provider should be timely, as dictated by clinical presentation and urgency of follow-up care required.
  2. The transition record should always include at least these data elements: principal diagnosis, medication list, contact information of the transferring physician, patient’s cognitive status, test results or pending results. An ideal transition record would add six more elements.
  3. All communications need to be secure, private, HIPAA-compliant, and accessible to patients and their providers.
  4. Communities need to develop standard data transfer forms, with the ability to modify information as a patient’s condition changes.
  5. The sending provider maintains responsibility for the care of the patient until the receiving provider confirms that the transfer is complete. The sending provider should be available to clarify issues of care, and the patient should be able to identify the responsible provider.
  6. Information transfer should be timely, as determined by transition setting, patient circumstances, level of acuity, and clear transition responsibility.
  7. Medical institutions must adopt national standards and establish processes to promote effective transitions of care.
  8. Standardized and evidence-based metrics related to these standards should be used for monitoring and improving transitions.

 

ONLINE-ONLY EXCLUSIVE

New Mammogram Recommendation Illustrates Complexity of Practice Guideline Use

By Chris Guadagnino, PhD

Even simple practice guidelines can be controversial. Guidelines are not created or implemented in a vacuum; they must be interpreted within a complex—and sometimes conflicting—milieu of medical, social, economic, and political forces.

This past November the U.S. Preventive Services Task Force, a federally funded, scientific advisory panel, released a 2009 update to its 2002 recommendations on breast cancer screening. The updated guideline said women in their 40s with an average risk for breast cancer do not need annual mammograms to screen for the disease, and older women at average risk of developing breast cancer need screening only once every two years.

The new guideline sparked disagreement among physicians, and a heated political debate as to whether the recommendation amounted to government-mandated, guideline-based, economically motivated healthcare rationing.

Some groups, including the American Cancer Society, said that mammograms have been proven to save lives by spotting tumors early on when they are most easily treated, and said they would stick by their current guideline to start annual mammogram screening at age 40. The Radiological Society of North America cited studies showing mammography of women in their 40s saves lives, and said about 20% of all breast cancer deaths in our country occur in women in their 40s.

The timing of the task force's recommendation was unfortunate (some lawmakers said it was calculated), as it was announced in the midst of the heated congressional healthcare reform debate. Although the new guideline would save a portion of the more than $5 billion spent on mammography in the U.S. each year, the task force said politics played no part in its recommendation, and that cost savings were never considered in its discussions. The task force acknowledged potential benefits of earlier testing, but attempted to balance those benefits with the potential harms of unnecessary radiation exposure, biopsies, overdiagnosis and overtreatment, and anxiety to women who get false positive results, which the panel said occurs in 10 percent of mammograms.


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