Making the Case for Early ID Specialist Involvement
In hospital settings, specialists are often consulted when managing patients with complex conditions, offering evidence-based recommendations on diagnosis and treatment plans. Infectious disease (ID) specialists are typically consulted when patients have one or more infectious conditions that are severe and require intensive monitoring. “ID specialists can assist hospitals in the inpatient setting by recommending appropriate antibiotic choices, duration of therapy, and route of delivery,” says Steven K. Schmitt, MD. “They can also help monitor patients to minimize adverse drug reactions.” Studies indicate that when an ID specialist is involved in patient care and the physician in charge follows ID recommendations, patients are more likely to receive a correct diagnosis. ID specialist involvement has also been associated with shorter lengths of stay (LOS), receipt of more appropriate therapies, fewer complications, and reduced use of antibiotics overall. However, data regarding the impact of ID specialists on hospital LOS and costs have been mixed. Many studies have been constrained by small sample size and chart review methodology, which limits the ability to generalize conclusions. As a result, it has been difficult to draw meaningful conclusions about the value of ID specialty interventions. Robust Data In a study published in Clinical Infectious Diseases, Dr. Schmitt and colleagues sought to generate robust data on the impact of ID consultation on spending and outcomes using a national Medicare claims database. Researchers looked at patients hospitalized with at least one of 11 serious but commonly treated infections. These included bacteremia, Clostridium difficile, central line-associated bloodstream infections, bacterial endocarditis, HIV/opportunistic infections, meningitis, osteomyelitis, prosthetic joint infections, septic arthritis, septic shock, and vascular device infections. Outcomes of a...
Surgical Readmissions and Quality of Care
Throughout the United States, reducing the rates of hospital readmissions has become a top priority, as evidenced by CMS planning to include surgical procedures in the expansion of the penalty program. “The hospital readmissions reduction program is predicated on the notion that decreasing the frequency with which patients return to hospitals can improve care and lower costs,” says Thomas C. Tsai, MD, MPH. “However, using medical readmission rates as a measure of hospital quality has been controversial.” Hospitals vary substantially in their medical readmission rates, but these data generally do not correlate with the measures that are often used to identify high-quality hospitals, such as mortality. This raises the question of whether or not medical readmission rates actually measure hospital quality or if they instead reflect other factors that are unrelated to hospital care. The relationship between readmission rates and surgical care may be different than that of medical readmissions. Most patients undergo non-urgent major surgery when they’re clinically stable. As a result, surgical readmissions are more likely to result from complications of care received during index hospitalizations. “Clinicians have relatively little information on the types of hospitals that perform well or poorly with regard to surgical readmission rates,” says Dr. Tsai, “but we hypothesized that hospitals excelling in surgical care would generally have fewer readmissions.” A Comprehensive Analysis In a study published in the New England Journal of Medicine, Dr. Tsai and colleagues sought to determine the patterns of surgical readmissions among Medicare patients across a set of major procedures in a national sample of hospitals. The study team combined information from Medicare claims, the American Hospital Association...
Reducing Readmissions in Community-Acquired Pneumonia
In the United States, community-acquired pneumonia (CAP) is the leading cause of morbidity and mortality due to infection and most often strikes the elderly and individuals with comorbidities. The 30-day mortality rate for Medicare patients admitted to the hospital for CAP is about 12% and has not changed significantly in decades (Table 1). CAP has been shown to increase long-term mortality to as high as 40% within 1 year of admission. The infection is one of seven conditions that account for nearly 30% of potentially preventable readmissions in the 15-day window after initial hospital discharge. Estimates show that the cost of treating CAP exceeds $17 billion per year. Hospitalizing Patients With Community-Acquired Pneumonia “The decision on whether or not hospitalization is necessary for CAP is critical because there are multiple consequences,” says Thomas M. File, Jr., MD, MSc. “Hospitalizations can influence the cost of care, the intensity of diagnostic testing, and the selection of antimicrobial agents.” There are several advantages to outpatient treatment of CAP—when used appropriately—including cost, patient preference, faster convalescence, and fewer nosocomial complications. Hospitalization decisions should be based on several factors, including (among others): age over 50; significant underlying coexisting conditions; elevated blood urea nitrogen levels; and the presence of altered mental status or significant abnormalities in vital signs. “Readmission for CAP patients recently discharged after hospitalization represents an important, expensive, and often preventable adverse outcome,” Dr. File says. “The risk of readmission can be modified by the quality and type of care that is provided. Improving CAP readmission rates is the joint responsibility of hospitals and clinicians.” He adds that measuring readmission rates can help...