The Benchmarks Committee has completed the data accumulation portion of the SHM 2005-2006 Productivity and Compensation Survey. As you might recall, we set a goal of 400 group respondents. With a final push for responses in early December, we exceeded our target. The responses were invaluable in making this survey a worthwhile effort and a credible reflection of the national hospitalist movement.
The Benchmarks Committee would like to specially thank those who attempted to complete the survey online and gave us feedback on this process. We had a few glitches with the online survey, and thanks to these folks and their communication we learned a few valuable lessons regarding this electronic process. We were able to intervene immediately and re-direct folks to the written survey. We’ll apply these lessons to the electronic component of future surveys as well.
Over the next few months we will be analyzing the data in preparation for presentation of the results to be offered up initially at the SHM Annual Meeting in Washington, D.C., the first week in May. (Visit www.hospitalmedicine.org under “Upcoming Events” to register.) Additionally, results will be available to survey participants online later in the year following the national presentation.
On a different note, the committee continues to work on the Hospitalist Dashboard Project. We are creating a dashboard that deals with metrics in the categories of resource utilization, clinical quality, productivity, and satisfaction.
Subsequently, we have worked through a Delphi process to whittle a long list of possible metrics down to 10 key metrics. These have been divided among the committee members, who will use an agreed-upon outline to write a brief description of the metric, how it is measured, and how it can be utilized to manage a hospitalist practice. The final product will be a white paper made available to the SHM membership.
How to Develop a Hospital-Based Palliative Care Program
Why your hospital needs such a program and how to create it
By Eva H. Chittenden, MD, and the SHM Palliative Care Task Force
Palliative care consists of medical care focused on the relief of suffering for patients living with chronic, advanced illness and it also helps their families. It is offered at any stage of disease, concurrently with all other appropriate medical treatment.
Palliative care providers treat the many physical symptoms that patients experience, including pain, dyspnea, nausea, and delirium. In addition, providers assist patients and families with complex medical decision-making, and attend to patients’ and families’ spiritual and psychosocial needs. Physicians work closely with an interdisciplinary team of nurses, chaplains, social workers, and pharmacists. Care continues beyond the point of death, with phone calls and consolation letters, as well as bereavement services.
Arguments for inpatient Palliative Care
The clinical imperative: We need better quality of care for people with serious and complex illness. The multicenter SUPPORT study, published in JAMA in 1995, looked at more than 9,000 hospitalized patients with life-threatening illness and demonstrated significant problems with pain and symptom control and with patient-doctor communication.1 Of the patients who died, more than 50% had moderate to severe pain more than half the time during the last three days of their lives. Of patients preferring do-not-resuscitate status, less than 50% of their physicians were aware of their wishes.
In another study, Nelson, et al. documented that more than half of cancer patients receiving intensive care had moderate to severe pain, anxiety, thirst, and hunger, and that 75% had moderate to severe discomfort of some kind.2 These studies have been a wake-up call to clinicians and hospitals across the country.
Patient and Family Preferences
Family members—especially women—shoulder most of the care of patients with serious illness. A minority of caregivers are over age 65 themselves and in ill health. When asked what they want from the medical system, family caregivers ask for help with transportation and personal care of their loved one at home, and for better home nursing support. They want 24/7 access to providers, better communication with their doctors, and to be remembered and contacted after the death of their family member.3-5 Caregiving itself has been shown to increase likelihood of premature mortality and lead to financial crisis.6
In the SUPPORT study, one-third of families lost most of their savings due to illness.7 Patients want pain and symptom control, avoidance of inappropriate prolongation of the dying process, and relief of burdens on family.8 Palliative care programs, both inpatient and ambulatory, can help provide families with needed services and improve communication at all levels.
The Demographic Argument
Hospitals need palliative care to effectively treat the growing numbers of people with serious, advanced, and complex illness. By 2030, the number of people over age 85 will double to almost 10 million.9 Many of these patients will have multiple chronic conditions, making their care complicated and expensive. And for many chronic conditions, including heart and lung disease, diabetes, and hypertension, death is not predictable.
Therefore, people need better care throughout the multiyear course of advanced illness. And while the Medicare Hospice Benefit is helpful for care of the dying (defined as people with six months or less to live) we need additional approaches for the much larger number of patients with chronic, progressive illness, years to live, continued benefit from disease-modifying therapy, and obvious palliative care needs.
The Educational Imperative
Hospitals are the site of training for most clinicians. Researchers have documented significant deficits in palliative care knowledge, skills, and attitudes among medical students, residents, and practicing physicians. Medical school and residency curricula, although improving, offer relatively little teaching in palliative care principles and practice.10,11
In 2000 the Liaison Committee on Medical Education mandated that medical school curricula include “important aspects of … end-of-life-care.” That same year the Accreditation Council for Graduate Medical Education encouraged internal medicine training programs to provide instruction in the principles of palliative care. Inpatient palliative care programs could provide much of this teaching through medical student and resident rotations, informal teaching during the consultation process, and through workshops and grand rounds.
The Financial Argument
Medical costs are rising exponentially due to multiple factors, including effective yet expensive new technologies and an expanding elderly population with more chronic conditions. Under the current Diagnosis Related Group (DRG) system, long, high-intensity hospital stays are causing a fiscal crisis for hospitals. The hospital and insurer of the future will have to work together to learn how to treat serious and complex illness efficiently and in the most cost-effective manner possible. Palliative care programs have the potential to ease this looming crisis through decreasing length of stay, both in the ICU and on the floors, and decreasing direct costs, including radiology, pharmacy, and laboratory costs. Researchers are beginning to document the positive fiscal impacts in rigorous studies.
Palliative Care: The Bottom Line
Palliative care teams have demonstrated improvement in pain and other symptom scores, in patient and family satisfaction with care, and in patient-provider communication. In addition, they have improved compliance with Joint Commission on Accreditation of Healthcare Organizations (JCAHO) quality measures. They have had these positive effects while simultaneously showing decreases in length of stay and costs. As a result, many programs have gained significant financial and administrative support from their hospitals.
Hospitalists and Palliative Care
Many hospitalist groups have found that building and staffing a palliative care consultation team is an important addition to their portfolio of services, further solidifying their value in the eyes of their hospital administration. The professional fee revenues are one more funding source, and palliative care is a critical service the group can provide the institution to improve the quality of care, improve patient satisfaction, and decrease costs.
The work involved in starting a program, including needs assessment, internal marketing, building a financial case, and developing a staffing model, is similar to that done when starting a hospitalist program. Hospitalists are ideally positioned to start palliative care services because they have already built relationships with key administrators and opinion leaders, and they understand the institution’s method for evaluating financial data, and how to access outcome and satisfaction data.
What Hospitalists Gain
By leading and staffing palliative care programs, hospitalists gain visibility and respect from colleagues, and improve their patients’ quality of care and their hospital’s financial bottom line. Clinically palliative care adds variety and depth to the work life of hospitalists and allows them to work with a rich interdisciplinary team. Although hospitalists should obtain additional training, they already possess the building blocks to provide excellent palliative care, such as skillfully leading family conferences and treating complex symptoms. When wearing the palliative care “hat,” providers have the luxury of spending more time at a patient’s bedside discussing what is truly important to the patient and his or her loved ones. The work is meaningful and rewarding.
Obtaining the Tools to Start a Program
The Center to Advance Palliative Care (CAPC), funded by the Robert Wood Johnson Foundation, is dedicated to advancing inpatient palliative care programs through their Web site (www.capc.org) and through their manual, “A Guide to Building a Hospital-Based Palliative Care Program,” available for purchase on its Web site.
In addition, CAPC sponsors the six national Palliative Care Leadership Centers (PCLCs) that each hold two-day, hands-on workshops on the nuts and bolts of starting inpatient palliative care programs, followed by a year of personalized mentoring by phone. The University of California, San Francisco’s PCLC, which is tailored specifically to hospitalists, will hold its last workshop in April 2006. For more information, visit www.capc.org/palliative-care-leadership-initiative.
At the upcoming SHM Annual Meeting in May, the Palliative Care Taskforce will present a workshop, “The Basic Why and How to Develop a Hospital-Based Palliative Care Program.”
Obtaining the Clinical Expertise
There are numerous opportunities for hospitalists to gain clinical expertise in palliative care, including Web-based and written materials and CME courses. Highlights include the Education in Palliative and End of Life Care programs; courses and study guides through the American Association of Hospice and Palliative Medicine, as well as Fast Facts (one-page synopses of relevant palliative care concepts that can be made into handouts or downloaded to one’s PDA). For more information on these resources and others, visit www.capc.org/palliative-care-professional-development/Education_Material_for _Professionals.
In addition, on Thursday, May 4, at 1:20, there will be a breakout session on pain management at the SHM Annual Meeting.
Hospitalists and other physicians can get certified in Hospice and Palliative Medicine by documenting relevant clinical experience and sitting for a qualifying exam. The American Board of Hospice and Palliative Medicine will administer its last exam in November 2006 (final application deadline is May 31, 2006). In September 2006 the field of Hospice and Palliative Medicine is expected to win American Board of Medical Specialties’ (ABMS) recognition as a subspecialty. After that the ABMS will take over administration of the exams. There will likely be a grandfathering period with the ABMS in which relevant clinical experience can substitute for completion of an ACGME-approved palliative care fellowship. For more information, visit the AAHPM Web site at www.abhpm.org/gfxc_100.aspx.
Inpatient palliative care programs benefit patients, hospitalists, and hospitals alike. Hospitalists are in the perfect position to lead the next generation of inpatient palliative care programs. Currently, about 20% of hospitals in the United States have programs. With the help of hospitalists, the percentage can increase significantly.
Special thanks to Diane Meier, MD, whose work inspired and informed this article.
- A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatment. The SUPPORT Principal Investigators. JAMA. 1995;274:1591-1598.
- Nelson JE, Meier DE, Oei EJ, et al. Self-reported
- symptom experience of critically ill cancer patients receiving intensive care. Crit Care Med. 2001;29 (2):277-282.
- Emanuel EJ, Fairclough DL, Slutsman J, et al. Assistance from family members, friends, paid care givers, and volunteers in the care of terminally ill patients. N Engl J Med. 1999;341 (13):956-963.
- Emanuel EJ, Fairclough DL, Slutsman J, et al. Understanding economic and other burdens of terminal Illness: the experience of patients and their caregivers. Ann Intern Med. 2000;132(6):451-459.
- Tolle et al. The Oregon report card: Improving care of the dying. 1999. Available at www.ohsu.edu/ethics/barriers2.pdf. Last accessed Feb. 3, 2006.
- Schulz R, Beach SR. Caregiving as a risk factor for mortality: the caregiver health effects study. JAMA. 1999;282 (23):2215-2219.
- Covinsky KE, Goldman L, Cook EF, et al. The impact of serious illness on patients’ families. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. JAMA. 1994;272:1839-1844.
- Singer PA, Martin DK, Kelner M. Quality end-of-life care: patients’ perspectives. JAMA. 1999;281(2):163-168.
- U.S. Interim Projections by Age, Sex, Race, and Hispanic Origin. Table 2a. US Census Bureau/CDC. 2002. Available at www.census.gov/ipc/www/usinterimproj/. Last accessed Feb. 3, 2006.
- Meier DE, Morrison RS, Cassel CK. Improving palliative care. Ann Intern Med. 1997;127:225-230.
- Billings JA, Block S. Palliative care in undergraduate medical education. Status report and future directions. JAMA. 1997;278:733-738.
New Hospitalist Productivity & Compensation Data
Survey results to be presented at 2006 SHM Annual Meeting
By the end of the data collection period in December 2005 approximately 400 hospital medicine programs had submitted responses for SHM’s 2005-2006 Hospitalist Productivity and Compensation Survey—a 35% increase from 2003. In addition to salary and production trends, this year’s survey should provide new insights into hospitalist responsibilities, the concerns of hospitalist program leaders, night coverage arrangements, and the use of nurse practitioners and physician assistants.
SHM thanks the program leaders who completed the comprehensive survey questionnaire. The following participants were randomly selected to receive awards:
- Danny Moore, MD, of Gilmore Memorial Hospital (Amory, Miss.) received a complimentary registration at the SHM Leadership Academy; and
- Four hospitalists received complimentary registration to the SHM Annual Meeting: Adrienne L. Bennett, MD, PhD, Ohio State University College of Medicine (Columbus, Ohio); Jasvinder S. Dhillon, St. Mary’s Hospital PICU Pediatric Hospitalist Program (Richmond, Va.); Howard Dubin, MD, Inpatient Medical Services of Bristol Hospital (Cheshire, Conn.); and Sujith Sundararaj MD, Signature Healthcare Solutions (Chicago).
The results of the 2005-2006 Hospitalist Productivity and Compensation Survey will be presented for the first time on Thursday, May 4 at 8:10 a.m. at the SHM Annual Meeting. A panel representing different perspectives within hospital medicine will react to the data. The panelists—SHM co-founder John Nelson, MD, President-Elect Mary Jo Gorman, MD, and Past-President Bob Wachter, MD—will represent hospital-employed practices, private groups, and academic programs, respectively. A report of the survey results will be available to survey participants for free. SHM members will be able to purchase the report at a discounted price. TH