Matt Garber
1. You are the chair of the AAP Section on Hospital medicine, chief of your division at Florida, a VIP Steering Committee member, and you manage to publish numerous papers, weigh in on the listserve, serve as a fellowship mentor, and more. How do you juggle all of these responsibilities and what advice do you have for others looking to get more involved on a national level?
My national activities started with volunteering for AAP opportunities, most of which I performed on my own time. In retrospect, I would suggest that people seek out fellowships and other academic training rather than the DIY path that I took. My current employer values the amazing work that VIP and the SOHM are doing, so my protected time is finally here. Maybe protected time is like research; it takes at least 17 years to implement. I am also not afraid of delegating (it’s kind of easy to make VIP successful when you have Shawn Ralston figuring out the science and young brilliant energetic people like Eric Biondi, Kavita Parikh, and Suni Kaiser running the projects and answering the 3 AM emails).
2. SHM is sponsoring the development of a second "Choosing Wisely" list for pediatric hospitalists with the support of the AAP and APA. Are there any topics that you’d like to see them take on in the next installation?
We just chose the AAP representatives and I’m sure they will be able to think further outside the box than I; perhaps some non-condition specific metrics like decreasing IV’s, IV fluids, IV antibiotics. We really need to figure out how to decrease unnecessary hospitalizations. Maybe that means collaborating with ED docs or PCPs, or maybe we can devise a system that allows us to be the gatekeepers and put ourselves out of business.
3. As the coauthor of the Hospital Pediatrics commentary, “Getting an “A”: Report Cards for Reducing Health Care Waste,” talking about eliminating low-value care and reducing waste to save money and provide better care. That sounds great in theory, but what can we as do at the individual level at our home institution to incorporate what you discuss here? What do you think is currently the most frustrating example of low value care in pediatric hospital medicine?
There are too many frustrating examples of low value care to choose just one, but I imagine that repeat MRIs for every seizure and abdominal CTs for diarrhea have to be some of the more expensive ones. One of the underlying themes in that commentary is that the federal government is not really doing much and we need to tackle this problem ourselves. As CQO at my last hospital, I got in quite a bit of trouble addressing low value care for conditions that PCPs were managing. Maybe discontinuing several dozen unnecessary ranitidine, prednisone, and albuterol prescriptions per year doesn’t do much, but we role model, teach learners, create pathways, participate in larger efforts. Heck I don’t know; I’m just waiting for Eric Coon to figure it out.
4. You are part of the VIP Steering Committee, which vets potential QI projects and ideas. Can you tell us more about VIP and how it might serve our readers?
VIP taps into the frustration so many hospitalists have with unnecessary, non-evidence based care, which is expensive, inconvenient and potentially harmful. The network targets overuse in common conditions using low cost tools anywhere children are hospitalized (small community hospitals to large children’s hospitals). We find that working with the AAP and hundreds of network members creates a culture that facilitates change in these diverse contexts. VIP supplies all the QI training and other tools necessary for success; joining a project is a great way to enact change locally and get involved nationally. We are hoping to branch out into some non-project activities and will be recruiting volunteers from community and university based settings to help with these endeavors soon.
5. In one listserve commentary, you mentioned empiric neonatal antibiotics, or more specifically the advantages of ampicillin/gentamicin over monotherapy with 3rd generation cephalosporin, more specifically coverage and resistance. Care to elaborate further?
Hey – no fair bringing up old listserv posts. I won’t even mention BAMF (if you get this in context you’re old – that means you Moises). Brian Alverson may have been the initial person to lead this charge. Oddly this issue arose during the flurry of epidemiologic papers showing that Listeria was pretty much gone (especially after 7 days of life in non-septic appearing neonates without meningitis) and rates of enterococcus were also quite low. This led people to advocate for cefotaxime or ceftriaxone alone without ampicillin, but then Brian and others made the point that ampicillin and gentamicin are less likely to cause antibiotic resistance than third generation cephalosporins. The combination is ideal for GBS; the gentamicin covers most Ecoli (and is probably ok for the first day of meningitis, though should be changed to cephalosporin when that is found), may be cheaper (gent is the drug all others are compared to for pricing), and still covers Listeria and enterococcus when they rarely occur. Others argue that the hidden costs arising from the frequency of dosing and the possible side effects of gent are problematic. I like to remind residents that aminoglycosides potentiate the paralysis of botulism and those patients often go down the rule out sepsis route even though afebrile. I agree with Brian that avoiding resistance trumps some of the other concerns though we have to be vigilant for Listeria risk factors, botulism and renal impairment when using this strategy. And yes, I just said I agree with Brian Alverson.
6. In October 2015, you co-authored a commentary in Hospital Pediatrics on strep throat. For most of us, treatment of strep colonization is something we see regularly. In addition to being annoying, it’s also frustrating because we as hospitalists often feel like it is outside of our control. Why do you think that this continues to be a problem and how can we as hospitalists aid the situation?
What is with all the strep testing? I joke that strep testing is frequently not performed at well visits, mandatory at all sick visits, and highly encouraged at ADHD checks. My excellent former resident Katie McMurray (now Pyle) did all the legwork on that one. My main contribution was this, “Strep throat is a fairly common illness with easily recognizable symptoms, potential serious sequelae, a rapid office-based test, and an inexpensive highly effective treatment. The busy pediatrician may be tempted to indiscriminately test children with a febrile illness and to treat those who test positive, believing he or she is preventing serious complications and also avoiding lengthy discussions of symptomatic care for viral illness.” I think that’s a lot of the problem (and the failure to recognize the decrease in acute rheumatic fever). Should we as hospitalists develop systems to give (and get) feedback from PCPs, ERs, and urgent care centers? This is time consuming and fraught with possible negative consequences, but I know others have been able to achieve it.
7. Not to rock the boat, but can you briefly summarize your take on oseltamivir and where we go from here with conflicting evidence/statements?
The SOHM dug pretty deeply into oseltamivir, and we had a very productive discussion with the Committee on Infectious Disease and a representative from the CDC about the evidence and AAP policy. Most people agree that oseltamivir has modest effects on healthy pediatric outpatients with influenza, and that there is little high quality data on sicker kids or inpatients. Reasonable people may extrapolate that oseltamivir may help prevent complications in hospitalized patients and advocate for broad use given no alternative medication. The sample size needed to power a prospective study in order to demonstrate a positive effect of oseltamivir in hospitalized children would be prohibitively large. I am concerned the harms may outweigh the benefits and the costs. The SOHM was also concerned about publication bias and industry influence in the published studies. My greatest concern is that there is nothing special about oseltamivir. Once you know how that sausage was made, well let’s just say vegetarianism is getting more attractive.
8. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
It’s the 25th anniversary of Liz Phair’s 1993 masterpiece “Exile in Guyville” (and Maria McKee’s 1993 masterpiece “You Gotta Sin to Get Saved”, though Maria failed to capitalize on the anniversary with a new boxed set like Liz did). Liz must have had some chutzpah, choosing a double album as her second release and comparing her work to the Rolling Stones’ 1972 “Exile on Main Street”, objectively the best album of all time. Apparently her boyfriend bristled at the idea of the double album, which only increased the artist’s determination. I’m not really going with some kind of uplifting take chances while you’re young story here, just wanted the SOHM library to state that “Exile on Main Street” is objectively the best album of all time.
My national activities started with volunteering for AAP opportunities, most of which I performed on my own time. In retrospect, I would suggest that people seek out fellowships and other academic training rather than the DIY path that I took. My current employer values the amazing work that VIP and the SOHM are doing, so my protected time is finally here. Maybe protected time is like research; it takes at least 17 years to implement. I am also not afraid of delegating (it’s kind of easy to make VIP successful when you have Shawn Ralston figuring out the science and young brilliant energetic people like Eric Biondi, Kavita Parikh, and Suni Kaiser running the projects and answering the 3 AM emails).
2. SHM is sponsoring the development of a second "Choosing Wisely" list for pediatric hospitalists with the support of the AAP and APA. Are there any topics that you’d like to see them take on in the next installation?
We just chose the AAP representatives and I’m sure they will be able to think further outside the box than I; perhaps some non-condition specific metrics like decreasing IV’s, IV fluids, IV antibiotics. We really need to figure out how to decrease unnecessary hospitalizations. Maybe that means collaborating with ED docs or PCPs, or maybe we can devise a system that allows us to be the gatekeepers and put ourselves out of business.
3. As the coauthor of the Hospital Pediatrics commentary, “Getting an “A”: Report Cards for Reducing Health Care Waste,” talking about eliminating low-value care and reducing waste to save money and provide better care. That sounds great in theory, but what can we as do at the individual level at our home institution to incorporate what you discuss here? What do you think is currently the most frustrating example of low value care in pediatric hospital medicine?
There are too many frustrating examples of low value care to choose just one, but I imagine that repeat MRIs for every seizure and abdominal CTs for diarrhea have to be some of the more expensive ones. One of the underlying themes in that commentary is that the federal government is not really doing much and we need to tackle this problem ourselves. As CQO at my last hospital, I got in quite a bit of trouble addressing low value care for conditions that PCPs were managing. Maybe discontinuing several dozen unnecessary ranitidine, prednisone, and albuterol prescriptions per year doesn’t do much, but we role model, teach learners, create pathways, participate in larger efforts. Heck I don’t know; I’m just waiting for Eric Coon to figure it out.
4. You are part of the VIP Steering Committee, which vets potential QI projects and ideas. Can you tell us more about VIP and how it might serve our readers?
VIP taps into the frustration so many hospitalists have with unnecessary, non-evidence based care, which is expensive, inconvenient and potentially harmful. The network targets overuse in common conditions using low cost tools anywhere children are hospitalized (small community hospitals to large children’s hospitals). We find that working with the AAP and hundreds of network members creates a culture that facilitates change in these diverse contexts. VIP supplies all the QI training and other tools necessary for success; joining a project is a great way to enact change locally and get involved nationally. We are hoping to branch out into some non-project activities and will be recruiting volunteers from community and university based settings to help with these endeavors soon.
5. In one listserve commentary, you mentioned empiric neonatal antibiotics, or more specifically the advantages of ampicillin/gentamicin over monotherapy with 3rd generation cephalosporin, more specifically coverage and resistance. Care to elaborate further?
Hey – no fair bringing up old listserv posts. I won’t even mention BAMF (if you get this in context you’re old – that means you Moises). Brian Alverson may have been the initial person to lead this charge. Oddly this issue arose during the flurry of epidemiologic papers showing that Listeria was pretty much gone (especially after 7 days of life in non-septic appearing neonates without meningitis) and rates of enterococcus were also quite low. This led people to advocate for cefotaxime or ceftriaxone alone without ampicillin, but then Brian and others made the point that ampicillin and gentamicin are less likely to cause antibiotic resistance than third generation cephalosporins. The combination is ideal for GBS; the gentamicin covers most Ecoli (and is probably ok for the first day of meningitis, though should be changed to cephalosporin when that is found), may be cheaper (gent is the drug all others are compared to for pricing), and still covers Listeria and enterococcus when they rarely occur. Others argue that the hidden costs arising from the frequency of dosing and the possible side effects of gent are problematic. I like to remind residents that aminoglycosides potentiate the paralysis of botulism and those patients often go down the rule out sepsis route even though afebrile. I agree with Brian that avoiding resistance trumps some of the other concerns though we have to be vigilant for Listeria risk factors, botulism and renal impairment when using this strategy. And yes, I just said I agree with Brian Alverson.
6. In October 2015, you co-authored a commentary in Hospital Pediatrics on strep throat. For most of us, treatment of strep colonization is something we see regularly. In addition to being annoying, it’s also frustrating because we as hospitalists often feel like it is outside of our control. Why do you think that this continues to be a problem and how can we as hospitalists aid the situation?
What is with all the strep testing? I joke that strep testing is frequently not performed at well visits, mandatory at all sick visits, and highly encouraged at ADHD checks. My excellent former resident Katie McMurray (now Pyle) did all the legwork on that one. My main contribution was this, “Strep throat is a fairly common illness with easily recognizable symptoms, potential serious sequelae, a rapid office-based test, and an inexpensive highly effective treatment. The busy pediatrician may be tempted to indiscriminately test children with a febrile illness and to treat those who test positive, believing he or she is preventing serious complications and also avoiding lengthy discussions of symptomatic care for viral illness.” I think that’s a lot of the problem (and the failure to recognize the decrease in acute rheumatic fever). Should we as hospitalists develop systems to give (and get) feedback from PCPs, ERs, and urgent care centers? This is time consuming and fraught with possible negative consequences, but I know others have been able to achieve it.
7. Not to rock the boat, but can you briefly summarize your take on oseltamivir and where we go from here with conflicting evidence/statements?
The SOHM dug pretty deeply into oseltamivir, and we had a very productive discussion with the Committee on Infectious Disease and a representative from the CDC about the evidence and AAP policy. Most people agree that oseltamivir has modest effects on healthy pediatric outpatients with influenza, and that there is little high quality data on sicker kids or inpatients. Reasonable people may extrapolate that oseltamivir may help prevent complications in hospitalized patients and advocate for broad use given no alternative medication. The sample size needed to power a prospective study in order to demonstrate a positive effect of oseltamivir in hospitalized children would be prohibitively large. I am concerned the harms may outweigh the benefits and the costs. The SOHM was also concerned about publication bias and industry influence in the published studies. My greatest concern is that there is nothing special about oseltamivir. Once you know how that sausage was made, well let’s just say vegetarianism is getting more attractive.
8. Jack Percelay often ends his list-serve commentary with the phrase “that’s just my 2 pennies.” What are your two cents?
It’s the 25th anniversary of Liz Phair’s 1993 masterpiece “Exile in Guyville” (and Maria McKee’s 1993 masterpiece “You Gotta Sin to Get Saved”, though Maria failed to capitalize on the anniversary with a new boxed set like Liz did). Liz must have had some chutzpah, choosing a double album as her second release and comparing her work to the Rolling Stones’ 1972 “Exile on Main Street”, objectively the best album of all time. Apparently her boyfriend bristled at the idea of the double album, which only increased the artist’s determination. I’m not really going with some kind of uplifting take chances while you’re young story here, just wanted the SOHM library to state that “Exile on Main Street” is objectively the best album of all time.