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Ahmed M, Islam M, Gogokhia L, Borz-Baba C, Wakefield D, Jakab SS. Hospital Utilization for Patients With Cirrhosis and Severe Ascites in a Model of Outpatient Paracentesis by Interventional Radiology. Cureus 2023; 15:e51397. [PMID: 38292997 PMCID: PMC10826452 DOI: 10.7759/cureus.51397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2023] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND Paracentesis is currently performed by interventional radiologists (IR) rather than gastroenterologists/hepatologists or internists. In this model of care, there is usually no evaluation of patients' renal function or adjustment of their medications at the time of paracentesis. The objectives of this study were to analyze hospital utilization and cirrhosis complications within six months of index outpatient paracentesis by IR and to identify potential areas of improvement in care. METHODS This is a retrospective study of patients with cirrhosis and ascites who underwent outpatient paracentesis by IR between October 15, 2015, and October 15, 2018, at a tertiary academic medical center. We collected demographics, data on cirrhosis etiology/complications, laboratory tests, provider notes, outpatient paracentesis dates, emergency department (ED) visits, hospitalizations, and ICU admissions within the following six months post index paracentesis. Associations between categorical predictors and clinical outcomes were analyzed using the chi-square test. Associations between quantitative predictors and clinical outcomes were analyzed using the Wilcoxon rank sum test. RESULTS Our study included 69 unique patients who had at least one outpatient encounter for paracentesis by IR in the study period. Most patients were men (71%), had alcohol-related cirrhosis as primary etiology (53.6%), an average age of 60 years, and an average Model for End-Stage Liver Disease-sodium (MELDNa) score at baseline of 16. Within six months from index paracentesis, 44 patients (64.7%) underwent repeat IR outpatient paracentesis (total 187 paracenteses, 4.25 paracenteses/patient), 43 patients (62.3%) had ER visits (total 118 ER visits, 2.8/patient), 41 patients (59.4%) had hospital admissions (total 88 admissions, 2.2/patient), and 11 patients required ICU admission. Complications of cirrhosis noted during follow-up included hepatic encephalopathy (40.5%), acute kidney injury (38.2%), upper gastrointestinal (UGI) bleeding (16%), and spontaneous bacterial peritonitis (SBP) in 15%. The mortality rate at six months was 20%. On multivariate analysis, the predictive factors for mortality were older age (p = 0.03) and MELDNa score (p = 0.02). Baseline MELDNa was predictive of acute kidney injury (p = 0.02), UGI bleed (p < 0.01), and ICU admission (p < 0.01), but not of SBP, encephalopathy, ED visit, or hospital admissions. Among patients with more than one paracentesis (64%),six patients underwent transjugular portosystemic shunt (TIPS), but there was no documentation of TIPS consideration in 31 patients (70.4%). A total of 20 patients (29%) were waitlisted for liver transplantation. CONCLUSION In this contemporary cohort of patients with cirrhosis undergoing outpatient IR paracentesis, we found a high rate of short-term cirrhosis complications and hospital utilization, while TIPS consideration was very low. Further data are needed to identify specific gaps in care, but IR paracentesis should be integrated within a multidisciplinary management model, with emphasis on early TIPS in eligible patients, as recommended by the current practice guidelines.
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Affiliation(s)
- Mustajab Ahmed
- Internal Medicine, Saint Mary's Hospital, Waterbury, USA
| | - Masuma Islam
- Internal Medicine, Saint Mary's Hospital, Waterbury, USA
| | - Lasha Gogokhia
- Gastroenterology and Hepatology, NewYork-Presbyterian Hospital, Weill Cornell Medicine, New York, USA
| | | | - Dorothy Wakefield
- Statistics, Department of Research, Saint Francis Hospital & Medical Center, Hartford, USA
| | - Sofia S Jakab
- Gastroenterology and Hepatology, Yale School of Medicine, New Haven, USA
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Brown C, Aksan N, Chang P, Jagannathan P, Ochi MG, Pignone M, Feagins L. Delayed Diagnostic Paracentesis Is Associated with Increased Preventable Healthcare Utilization in Disadvantaged Patient Populations with Advanced Liver Disease and Elevated INR. Dig Dis Sci 2023:10.1007/s10620-023-07937-x. [PMID: 37052775 DOI: 10.1007/s10620-023-07937-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 03/25/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND Patients hospitalized with cirrhosis, ascites, and elevated INR often experience delays in timely diagnostic paracentesis. AIMS Identify whether delays in diagnostic paracentesis were associated with adverse outcomes in a hospital system serving a large disadvantaged population. METHODS Retrospective cohort analysis of patients admitted from January 2017 to October 2019 with cirrhosis, ascites, and INR ≥ 1.5 across a multi-hospital health system in central Texas. We examined demographic and clinical characteristics of patients with diagnostic paracentesis (1) ≤ 24 h; (2) > 24 h; (3) therapeutic only or no paracentesis. We used logistic regression to examine differences in clinical outcomes controlling for confounders. RESULTS 479 patients met inclusion criteria. 30.0% (N = 143) were Latino, 6.7% (N = 32) African American, and 67.8% (N = 325) under or uninsured. 54.1% of patients received a diagnostic paracentesis ≤ 24 h of admission and 21.1% did not receive a diagnostic paracentesis during the hospitalization. Undergoing diagnostic paracentesis > 24 h of admission was associated with a 2.3 day increase in length of stay (95% CI 0.8-3.8), and OR 1.7 for an Emergency Room visit within 30 days of discharge (95% CI 1.1-2.7) compared to receiving a diagnostic paracentesis ≤ 24 h. Patients receiving diagnostic paracentesis in radiology were more likely to have a delay in procedure OR 5.8 (95% CI 2.8-8.6). CONCLUSION Delayed diagnostic paracentesis is associated with increased preventable healthcare utilization compared with timely diagnostic paracentesis. Health systems should support efforts to ensure timely diagnostic paracentesis for patients with advanced liver disease, including performance at the bedside.
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Affiliation(s)
- Cristal Brown
- Dell Medical School, University of Texas at Austin, Austin, USA.
- Gastroenterology and Hepatology, The University of Texas at Austin Dell Medical School, Health Discovery Building, 1601 Trinity St Z0900, Austin, TX, 78712, USA.
| | - Nazan Aksan
- Dell Medical School, University of Texas at Austin, Austin, USA
| | - Patrick Chang
- Dell Medical School, University of Texas at Austin, Austin, USA
| | | | | | - Michael Pignone
- Dell Medical School, University of Texas at Austin, Austin, USA
| | - Linda Feagins
- Dell Medical School, University of Texas at Austin, Austin, USA
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Seah DS, Wilcock A, Chang S, Sousa MS, Sinnarajah A, Teoh CO, Allan S, Chye R, Doogue M, Hunt J, Agar M, Currow DC. Paracentesis for cancer-related ascites in palliative care: An international, prospective cohort study. Palliat Med 2022; 36:1408-1417. [PMID: 36113139 DOI: 10.1177/02692163221122326] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Paracentesis is commonly undertaken in patients with cancer-related ascites. AIM To systematically investigate the symptomatic benefits and harms experienced by patients with cancer undergoing paracentesis using real-world data in the palliative care setting. DESIGN Prospective, multisite, observational, consecutive cohort study. Benefits and harms of paracentesis were assessed between 01/07/2018 and 31/02/2021 as part of routine clinical assessments by treating clinicians at four timepoints: (T0) before paracentesis; (T1) once drainage ceased; (T2) 24 h after T1 and (T3) 28 days after T1 or next paracentesis, if sooner. SETTING/PARTICIPANTS Data were collected from 11 participating sites across five countries (Australia, England, Hong Kong, Malaysia and New Zealand) on 111 patients undergoing paracentesis via a temporary (73%) or indwelling (21%) catheter: 51% male, median age 69 years, Australia-modified Karnofsky Performance Score 50. RESULTS At T1 (n = 100), symptoms had improved for most patients (81%), specifically abdominal distension (61%), abdominal pain (49%) and nausea (27%), with two-thirds experiencing improvement in ⩾2 symptoms. In the remaining patients, symptoms were unchanged (7%) or worse (12%). At least one harm occurred in 32% of patients, the most common being an ascitic leak (n = 14). By T3, 89% of patients had experienced some benefit and 36% some harm, including four patients who experienced serious harm, one of which was a fatal bowel perforation. CONCLUSION Most patients obtained rapid benefits from paracentesis. Harms were less frequent and generally mild, but occasionally serious and fatal. Our findings help inform clinician-patient discussions about the potential outcomes of paracentesis in this frail population.
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Affiliation(s)
- Davinia Se Seah
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia.,Sacred Heart Health Service, Sydney, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Andrew Wilcock
- Hayward House Specialist Palliative Care Unit, School of Clinical Oncology, University of Nottingham, Nottingham, England
| | - Sungwon Chang
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Mariana S Sousa
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Aynharan Sinnarajah
- Division of Palliative Medicine, Department of Medicine, School of Medicine, Queen's University, Kingston, ON, Canada
| | | | | | - Richard Chye
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia.,Sacred Heart Health Service, Sydney, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Matthew Doogue
- University of Otago - Christchurch & Canterbury District Health Board, Christchurch, New Zealand
| | - Jane Hunt
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Meera Agar
- IMPACCT-Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - David C Currow
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, Australia
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Nandan A, Wang D, Bosinski C, Tahir P, Wang S, Sonenthal PD, Shafiq M. Characteristics and impact of bedside procedure services in the United States: A systematic review. J Hosp Med 2022; 17:644-652. [PMID: 35662415 DOI: 10.1002/jhm.12848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 04/30/2022] [Accepted: 05/05/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bedside procedure services are increasingly employed within internal medicine departments to meet clinical needs and improve trainee education. Published literature on these largely comprises single-center studies; an updated systematic review is needed to synthesize available data. PURPOSE This review examined published literature on the structure and function of bedside procedure services and their impact on clinical and educational outcomes (PROSPERO ID: 192466). DATA SOURCES Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework, multiple databases were searched for publications from 2000 to 2021. STUDY SELECTION, DATA EXTRACTION, AND DATA SYNTHESIS Thirteen single-center studies were identified, including 12 observational studies and 1 randomized trial. Data were synthesized in tabular and narrative format. Services were typically staffed by hospitalists or pulmonologists. At a minimum, each offered paracentesis, thoracentesis, and lumbar puncture. While there was considerable heterogeneity in service structures, these broadly fit either Model A (service performing the procedure) or Model B (service supervising the primary team). Procedure services led to increases in procedure volumes and self-efficacy among medical residents. Assessment of clinical outcomes was limited by heterogeneous definitions of complication rates and by sparse head-to-head data involving suitable comparators. Published data pointed to high success rates, low complication rates, and high patient satisfaction, with a recent study also demonstrating a decreased length of stay. CONCLUSIONS There are relatively few published studies describing the characteristics of bedside procedure services and their impact on clinical and educational outcomes. Limited data point to considerable heterogeneity in service design, a positive impact on medical trainees, and a positive impact on patient-related outcomes.
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Affiliation(s)
- Anirudh Nandan
- Department of Medicine, University of California, San Francisco, California, USA
| | - David Wang
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Cameron Bosinski
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Peggy Tahir
- Research and Copyright Librarian, University of California, San Francisco, California, USA
| | - Sally Wang
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Paul D Sonenthal
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Majid Shafiq
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Williams JP, Nathanson R, LoPresti CM, Mader MJ, Haro EK, Drum B, O'Brien E, Khosla R, Boyd JS, Bales B, Wetherbee E, Sauthoff H, Schott CK, Basrai Z, Resop D, Lucas BP, Soni NJ. Current use, training, and barriers in point-of-care ultrasound in hospital medicine: A national survey of VA hospitals. J Hosp Med 2022; 17:601-608. [PMID: 35844080 DOI: 10.1002/jhm.12911] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 05/18/2022] [Accepted: 05/29/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND Point-of-care ultrasound (POCUS) can reduce procedural complications and improve the diagnostic accuracy of hospitalists. Currently, it is unknown how many practicing hospitalists use POCUS, which applications are used most often, and what barriers to POCUS use exist. OBJECTIVE This study aimed to characterize current POCUS use, training needs, and barriers to use among hospital medicine groups (HMGs). DESIGN, SETTING, AND PARTICIPANTS A prospective observational study of all Veterans Affairs (VA) medical centers was conducted between August 2019 and March 2020 using a web-based survey sent to all chiefs of HMGs. These data were compared to a similar survey conducted in 2015. RESULT Chiefs from 117 HMGs were surveyed, with a 90% response rate. There was ongoing POCUS use in 64% of HMGs. From 2015 to 2020, procedural POCUS use decreased by 19%, but diagnostic POCUS use increased for cardiac (8%), pulmonary (7%), and abdominal (8%) applications. The most common barrier to POCUS use was lack of training (89%), and only 34% of HMGs had access to POCUS training. Access to ultrasound equipment was the least common barrier (57%). The proportion of HMGs with ≥1 ultrasound machine increased from 29% to 71% from 2015 to 2020. An average of 3.6 ultrasound devices per HMG was available, and 45% were handheld devices. CONCLUSION From 2015 to 2020, diagnostic POCUS use increased, while procedural use decreased among hospitalists in the VA system. Lack of POCUS training is currently the most common barrier to POCUS use among hospitalists.
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Affiliation(s)
- Jason P Williams
- Medical Education, Atlanta VA Medical Center, Medicine Service, Atlanta, Georgia, USA
- Division of Hospital Medicine, Emory School of Medicine, Atlanta, Georgia, USA
| | - Robert Nathanson
- Department of Medicine, South Texas Veterans Health Care System, Medicine Service, San Antonio, Texas, USA
- Division of General & Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Charles M LoPresti
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Michael J Mader
- Department of Medicine, South Texas Veterans Health Care System, Research Service, San Antonio, Texas, USA
| | - Elizabeth K Haro
- Department of Medicine, South Texas Veterans Health Care System, Medicine Service, San Antonio, Texas, USA
- Division of Pulmonary Diseases & Critical Care Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Brandy Drum
- Department of Veterans Affairs, Healthcare Analysis and Information Group, Milwaukee, Wisconsin, USA
| | - Edward O'Brien
- Department of Veterans Affairs, Healthcare Analysis and Information Group, Milwaukee, Wisconsin, USA
| | - Rahul Khosla
- Department of Pulmonary, Critical Care and Sleep Medicine, George Washington University Medical Faculty Associates, Washington, District of Columbia, USA
- Pulmonary and Critical Care Medicine, Washington Veterans Affairs Medical Center, Washington, District of Columbia, USA
| | - Jeremy S Boyd
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Emergency Medicine, VA Tennessee Valley Healthcare System-Nashville, Nashville, Tennessee, USA
| | - Brian Bales
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Emergency Medicine, VA Tennessee Valley Healthcare System-Nashville, Nashville, Tennessee, USA
| | - Erin Wetherbee
- Pulmonary Section, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Harald Sauthoff
- Medicine Service, VA NY Harbor Healthcare System, New York, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, New York University School of Medicine, New York, New York, USA
| | - Christopher K Schott
- Critical Care Service, VA Pittsburgh Health Care Systems, Pittsburgh, Pennsylvania, USA
- Departments of Critical Care Medicine and Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Zahir Basrai
- Emergency Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Dana Resop
- Department of Emergency Medicine, University of Wisconsin, Madison, Wisconsin, USA
- Emergency Department, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, USA
| | - Brian P Lucas
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont, USA
- Department of Medicine, Dartmouth Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Nilam J Soni
- Department of Medicine, South Texas Veterans Health Care System, Medicine Service, San Antonio, Texas, USA
- Division of General & Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
- Division of Pulmonary Diseases & Critical Care Medicine, University of Texas Health San Antonio, San Antonio, Texas, USA
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Growth in Thoracentesis and Paracentesis Performed by Radiology and Advanced Practice Providers: Medicare Volume and Reimbursement Trends From 2012 to 2018. J Am Coll Radiol 2022; 19:597-603. [PMID: 35341699 DOI: 10.1016/j.jacr.2022.02.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/15/2022] [Accepted: 02/18/2022] [Indexed: 11/21/2022]
Abstract
PURPOSE To study trends in volume and reimbursement for paracentesis and thoracentesis by physicians and advanced practice providers (APPs) after the introduction of discreet Current Procedural Terminology codes for image-guidance. METHODS Medicare claims for 2012 to 2018 (paracentesis) and 2013 to 2018 (thoracentesis) were extracted using Current Procedural Terminology codes for blind and image-guided paracentesis and thoracentesis. Total volumes were analyzed by provider specialty. Nonfacility reimbursement and relative value units were compared. RESULTS For blind paracentesis, volume decreased from 17,393 to 12,226 procedures from 2012 to 2018. Conversely, volume of image-guided paracentesis increased from 171,631 to 253,834 procedures. Radiology performed the majority of image-guide paracentesis (83.9% in 2012 and 77.1% in 2018). Volume and relative share for APPs dramatically increased (from 10.2% to 15.8%). For blind thoracentesis, volume decreased from 26,716 to 15,075 procedures from 2013 to 2018. Conversely, volume of image-guided thoracentesis increased from 187,168 to 222,673 procedures. Radiology performed the majority of image-guided thoracentesis (73.6% in 2013 and 66.2% in 2018). Volume and relative share for APPs dramatically increased (from 7.7% to 12.9%). Although reimbursement for both image-guided paracentesis and thoracentesis decreased, their reimbursement remained higher than that of blind paracentesis and thoracentesis throughout the study period. CONCLUSION A higher percentage of these procedures are being performed using image guidance; radiologists performed a growing number but declining percentage of image-guided paracentesis and thoracentesis. APPs are playing an increasing role, particularly using image-guidance. Given decreasing reimbursement for these procedures, APPs can provide a large cost advantage in procedural radiology practices.
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Johnson DR, Waid MD, Rula EY, Hughes DR, Rosenkrantz AB, Duszak R. Comparison of Radiologists and Other Specialists in the Performance of Lumbar Puncture Procedures Over Time. AJNR Am J Neuroradiol 2021; 42:1174-1181. [PMID: 33664117 DOI: 10.3174/ajnr.a7049] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 11/26/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Lumbar punctures may be performed by many different types of health care providers. We evaluated the percentages of lumbar punctures performed by radiologists-versus-nonradiologist providers, including changes with time and discrepancies between specialties. MATERIALS AND METHODS Lumbar puncture procedure claims were identified in a 5% sample of Medicare beneficiaries from 2004 to 2017 and classified by provider specialty, site of service, day of week, and patient complexity. Compound annual growth rates for 2004 versus 2017 were calculated; t test and χ2 statistical analyses were performed. RESULTS Lumbar puncture use increased from 163.3 to 203.4 procedures per 100,000 Medicare beneficiaries from 2004 to 2017 (overall rate, 190.3). Concurrently, the percentage of lumbar punctures performed by radiologists increased from 37.1% to 54.0%, while proportions performed by other major physician specialty groups either declined (eg, neurologists from 23.5% to 10.0%) or were largely unchanged. While radiologists saw the largest absolute increase in the percentage of procedures, the largest relative increase occurred for nonphysician providers (4.2% in 2004 to 7.5% in 2017; +78.6%). In 2017, radiologists performed most procedures on weekdays (56.2%) and a plurality on weekends (38.2%). Comorbidity was slightly higher in patients undergoing lumbar puncture by radiologists (P < .001). CONCLUSIONS Radiologists now perform most lumbar puncture procedures for Medicare beneficiaries in both the inpatient and outpatient settings. The continuing shift in lumbar puncture responsibility from other specialists to radiologists has implications for clinical workflows, cost, radiation exposure, and postgraduate training.
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Affiliation(s)
- D R Johnson
- From the Department of Radiology (D.R.J.), Mayo Clinic, Rochester, Minnesota
- Department of Neurology (D.R.J.), Mayo Clinic, Rochester, Minnesota
| | - M D Waid
- Harvey L. Neiman Health Policy Institute (M.D.W., E.Y.R., D.R.H.), Reston, Virginia
| | - E Y Rula
- Harvey L. Neiman Health Policy Institute (M.D.W., E.Y.R., D.R.H.), Reston, Virginia
| | - D R Hughes
- Harvey L. Neiman Health Policy Institute (M.D.W., E.Y.R., D.R.H.), Reston, Virginia
- School of Economics (D.R.H.), Georgia Institute of Technology, Atlanta, Georgia
| | - A B Rosenkrantz
- Department of Radiology (A.B.R.), NYU Langone Health, New York, New York
| | - R Duszak
- Department of Radiology and Imaging Sciences (R.D.), Emory University School of Medicine, Atlanta, Georgia
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Cool JA, Huang GC. Procedural Competency Among Hospitalists: A Literature Review and Future Considerations. J Hosp Med 2021; 16:230-235. [PMID: 33734979 DOI: 10.12788/jhm.3590] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 01/11/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND As general internists practicing in the inpatient setting, hospitalists at many institutions are expected to perform invasive bedside procedures, as defined by professional standards. In reality, hospitalists are doing fewer procedures and increasingly are referring to specialists, which threatens their ability to maintain procedural skills. The discrepancy between expectations and reality, especially when hospitalists may be fully credentialed to perform procedures, poses significant risks to patients because of morbidity and mortality associated with complications, some of which derive from practitioner inexperience. METHODS We performed a structured search of the peer-reviewed literature to identify articles focused on hospitalists performing procedures. RESULTS Our synthesis of the literature characterizes contributors to hospitalists' procedural competency and discusses: (1) temporal trends for procedures performed by hospitalists and their associated referral patterns, (2) data comparing use and clinical outcomes of procedures performed by hospitalists compared with specialists, (3) the lack of nationwide standardization of hospitalist procedural training and credentialing, and (4) the role of medical procedure services, although limited in supportive evidence, in concentrating procedural skill and mitigating risk in the hands of a few well-trained hospitalists. CONCLUSION We conclude with recommendations for hospital medicine groups to ensure the safety of hospitalized patients undergoing bedside procedures.
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Affiliation(s)
- Joséphine A Cool
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Grace C Huang
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
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