Physician-Pharmacist collaboration in a pay for performance healthcare environment

Healthcare is becoming more complex and costly in both European (Slovak) and American models. Healthcare in the United States (U.S.) is undergoing a particularly dramatic change. Physician and hospital reimbursement are becoming less procedure focused and increasingly outcome focused. Efforts at Mercy Hospital have shown promise in terms of collaborative team based care improving performance on glucose control outcome metrics, linked to reimbursement. Our performance on the Centers for Medicare and Medicaid Services (CMS) post-operative glucose control metric for cardiac surgery patients increased from a 63.6% pass rate to a 95.1% pass rate after implementing interventions involving physician-pharmacist team based care.Having a multidisciplinary team that is able to adapt quickly to changing expectations in the healthcare environment has aided our institution. As healthcare becomes increasingly saturated with technology, data and quality metrics, collaborative efforts resulting in increased quality and physician efficiency are desirable.

CONCLUSION

Multidisciplinary collaboration (including physician-pharmacist collaboration) appears to be a viable route to improved performance in an outcome based healthcare system (Fig. 2, Ref. 12).

Hospitalist-pharmacist collaboration. A success story of the integration of a clinical pharmacist on the multidisciplinary hospitalist team

The goals of hospitalist programs in the United States include improving the quality of care, patient safety, the efficient use of resources and reducing the variation in diagnostic and therapeutic approaches. Hospitalist medicine aims to bring together the concepts of provision of evidence-based medicine as well as the financial considerations of managed care. Hospital-based clinical pharmacists have a unique knowledge-base and collaboration with hospitalist physicians comes naturally. This paper will discuss the role of the clinical pharmacist on the multidisciplinary team that strives to implement the ideals and intentions of these two forces.

CONCLUSION

We believe the Slovak healthcare system shares the same goals for hospital-based physicians of improving the quality of care, patient safety, the efficient use of resources and minimization of variation in diagnostic and therapeutic approaches. Many aspects of the hospitalist model of healthcare could be implemented in order to reach these goals in the changing Slovak healthcare systems. Implementation of a hospitalist model along with the recognition of the value of the hospital-based clinical pharmacists would be predicted to lead to achievement of these goals (Ref. 12). Full Text in free PDF www.bmj.sk.

Central venous pressure--evaluation, interpretation, monitoring, clinical implications

Physicians need to understand, evaluate and address hemodynamics in every patient and even more importantly in patients that are critically ill. Being able to determine and interpret central venous pressure is one of the most useful bedside evaluation skills, even in the 21st century (Fig. 3). Full Text (Free, PDF) www.bmj.sk.

New trends in the management of inpatients in U.S. hospitals--quality measurements and evidence-based medicine in practice

OBJECTIVES

To summarize and analyze the Premier/CMS Hospital Quality Incentive Demonstration (HQID) Project that is being conducted in the U.S. and to propose acceptance and implementation of similar initiatives in Slovak health care.

BACKGROUND

New trends in the management of hospitalized patients in the United States include standardization of medical care, application of evidence-based medicine in everyday medical practice, introduction and usage of computerized medical documentation (including computerized physician order entry), efficient use of financial resources, detailed measurements of outcomes, and availability of the data to the public. Centers for Medicaid and Medicare Services (CMS), largest third party payer in the U.S., has introduced the pay-for-performance (P4P) initiative, a new pilot program designed to promote high quality medical care based on evidence-based medicine by reimbursing top performing hospitals at a higher level than poor performing hospitals. The primary objectives of this program include increasing clinical quality and saving lives. A secondary objective is to improve the cost-effectiveness of health care delivery.

RESULTS

Data from the first year of the CMS/Premier Hospital Quality Incentive Demonstration Project reflect a significant improvement in the quality of care across five clinical focus areas as measured by 33 nationally standardized and widely accepted quality indicators. The average improvement across the clinical areas was 6.6%. These performance gains have outpaced those of hospitals involved in other national performance initiatives. An evidence-based analysis suggests that the lives of approximately 235 acute myocardial infarction patients were saved as a result of quality improvements in that related focus area alone.

CONCLUSION

The author believes that similar programs can have a beneficial impact on the Slovak health care system and can promote and encourage the broader introduction of evidence-based medicine in hospitals in Slovakia (Tab. 2, Fig. 2, Ref. 7).

Free radicals, metals and antioxidants in oxidative stress-induced cancer

Oxygen-free radicals, more generally known as reactive oxygen species (ROS) along with reactive nitrogen species (RNS) are well recognised for playing a dual role as both deleterious and beneficial species. The "two-faced" character of ROS is substantiated by growing body of evidence that ROS within cells act as secondary messengers in intracellular signalling cascades, which induce and maintain the oncogenic phenotype of cancer cells, however, ROS can also induce cellular senescence and apoptosis and can therefore function as anti-tumourigenic species. The cumulative production of ROS/RNS through either endogenous or exogenous insults is termed oxidative stress and is common for many types of cancer cell that are linked with altered redox regulation of cellular signalling pathways. Oxidative stress induces a cellular redox imbalance which has been found to be present in various cancer cells compared with normal cells; the redox imbalance thus may be related to oncogenic stimulation. DNA mutation is a critical step in carcinogenesis and elevated levels of oxidative DNA lesions (8-OH-G) have been noted in various tumours, strongly implicating such damage in the etiology of cancer. It appears that the DNA damage is predominantly linked with the initiation process. This review examines the evidence for involvement of the oxidative stress in the carcinogenesis process. Attention is focused on structural, chemical and biochemical aspects of free radicals, the endogenous and exogenous sources of their generation, the metal (iron, copper, chromium, cobalt, vanadium, cadmium, arsenic, nickel)-mediated formation of free radicals (e.g. Fenton chemistry), the DNA damage (both mitochondrial and nuclear), the damage to lipids and proteins by free radicals, the phenomenon of oxidative stress, cancer and the redox environment of a cell, the mechanisms of carcinogenesis and the role of signalling cascades by ROS; in particular, ROS activation of AP-1 (activator protein) and NF-kappaB (nuclear factor kappa B) signal transduction pathways, which in turn lead to the transcription of genes involved in cell growth regulatory pathways. The role of enzymatic (superoxide dismutase (Cu, Zn-SOD, Mn-SOD), catalase, glutathione peroxidase) and non-enzymatic antioxidants (Vitamin C, Vitamin E, carotenoids, thiol antioxidants (glutathione, thioredoxin and lipoic acid), flavonoids, selenium and others) in the process of carcinogenesis as well as the antioxidant interactions with various regulatory factors, including Ref-1, NF-kappaB, AP-1 are also reviewed.

Effective management of hospitalized patients--established role of hospitalists in the USA

OBJECTIVES

Summarize and present benefits of effective management of inpatients in US hospitals by hospitalists and discuss the possible implications for healthcare system in Slovakia.

BACKGROUND

Inpatient or hospital-based internal medicine started to separate from traditional office-based medicine about a decade ago. Today, hospitalist programs are an integral part of most progressive hospitals in the US and the value of such programs is well documented.

METHODS

Literature review and analysis of Mercy Medical Center-North Iowa hospitalist program.

RESULTS

Hospitalists improve the quality of care for hospitalized patients, use fewer resources and decrease the length of stay. In 1998 there were 2,000 hospitalists and in 2005 there were more than 15,000 hospitalists in more than 1,800 programs throughout the US. It is projected that by the end of the decade there will be more than 30,000 hospitalists in the US. Mercy Hospital started its hospitalist program in 1999 with one hospitalist and by July 2006 the program will expand to six physicians. The average daily census for a hospitalist is 20 patients and the average length of stay is 3 days. In 2003, with 874 median new admits and consults per year per hospitalist, one hospitalist was able to save approximately dollars 400,000/year compared to the traditional internal medicine model.

CONCLUSION

Hospitalists are the fastest growing specialty in the US. In addition to the care of medical illnesses including subspecialty and surgical consults, hospitalists also serve as stewards of hospital systems. They improve quality, patient safety, efficient use of resources and reduce variation in diagnostic and therapeutic approaches (Tab. 2, Fig. 3, Ref. 10).