Bryan Lublin, MD, MPH

Background: Alterations to the coagulation cascade put cirrhotic patients at higher risk for bleeding and thrombotic complications.

Study design: Expert review.

Setting: Literature review.

Synopsis: The authors provide 12 best practice recommendations, including use blood products sparingly in the absence of active bleeding out of concern for raising portal pressures; low-risk paracentesis, thoracentesis, and upper endoscopy do not require routine correction of thrombocytopenia or coagulopathy; for active bleeding or high-risk procedures, correct hematocrit to above 25%, platelets to more than 50,000, and fibrinogen to above 120 mg/dL; the risk of thrombosis, including venous thromboembolism and portal vein thrombosis, is high in these patients despite elevated INR values.

As such, pharmacologic VTE prophylaxis is often underutilized in patients admitted with cirrhosis; for patients requiring therapeutic anticoagulation, direct oral anticoagulants are safe in stable patients with mild cirrhosis, but should be avoided in Child-Pugh B and C patients.

Bottom line: Cirrhotic patients do not require routine correction of coagulopathy prior to low-risk procedures.

Citation: O’Leary JG et al. AGA Clinical Practice Update: Coagulation in cirrhosis. Gastroenterology. 2019. doi: 10.1053/j.gastro.2019.03.070.

Dr. Lublin is a hospitalist at the University of Colorado at Denver, Aurora.

Background: Alterations to the coagulation cascade put cirrhotic patients at higher risk for bleeding and thrombotic complications.

Study design: Expert review.

Setting: Literature review.

Synopsis: The authors provide 12 best practice recommendations, including use blood products sparingly in the absence of active bleeding out of concern for raising portal pressures; low-risk paracentesis, thoracentesis, and upper endoscopy do not require routine correction of thrombocytopenia or coagulopathy; for active bleeding or high-risk procedures, correct hematocrit to above 25%, platelets to more than 50,000, and fibrinogen to above 120 mg/dL; the risk of thrombosis, including venous thromboembolism and portal vein thrombosis, is high in these patients despite elevated INR values.

As such, pharmacologic VTE prophylaxis is often underutilized in patients admitted with cirrhosis; for patients requiring therapeutic anticoagulation, direct oral anticoagulants are safe in stable patients with mild cirrhosis, but should be avoided in Child-Pugh B and C patients.

Bottom line: Cirrhotic patients do not require routine correction of coagulopathy prior to low-risk procedures.

Citation: O’Leary JG et al. AGA Clinical Practice Update: Coagulation in cirrhosis. Gastroenterology. 2019. doi: 10.1053/j.gastro.2019.03.070.

Dr. Lublin is a hospitalist at the University of Colorado at Denver, Aurora.

Background: Alterations to the coagulation cascade put cirrhotic patients at higher risk for bleeding and thrombotic complications.

Study design: Expert review.

Setting: Literature review.

Synopsis: The authors provide 12 best practice recommendations, including use blood products sparingly in the absence of active bleeding out of concern for raising portal pressures; low-risk paracentesis, thoracentesis, and upper endoscopy do not require routine correction of thrombocytopenia or coagulopathy; for active bleeding or high-risk procedures, correct hematocrit to above 25%, platelets to more than 50,000, and fibrinogen to above 120 mg/dL; the risk of thrombosis, including venous thromboembolism and portal vein thrombosis, is high in these patients despite elevated INR values.

As such, pharmacologic VTE prophylaxis is often underutilized in patients admitted with cirrhosis; for patients requiring therapeutic anticoagulation, direct oral anticoagulants are safe in stable patients with mild cirrhosis, but should be avoided in Child-Pugh B and C patients.

Bottom line: Cirrhotic patients do not require routine correction of coagulopathy prior to low-risk procedures.

Citation: O’Leary JG et al. AGA Clinical Practice Update: Coagulation in cirrhosis. Gastroenterology. 2019. doi: 10.1053/j.gastro.2019.03.070.

Dr. Lublin is a hospitalist at the University of Colorado at Denver, Aurora.

Background: The United States Renal Data System registry estimates that approximately 30% of patients die within 1 year of initiating hemodialysis.

Study design: Retrospective, observational analysis.

Setting: The Health and Retirement Study is a nationally representative survey of Medicare beneficiaries during 1998-2014. Medicare claims were linked to mortality data from the National Death Index.

Synopsis: Among 391 patients who initiated dialysis, 22.5%, 44.2%, and 54.5% died within 30 days, 6 months, and 1 year, respectively. After multivariate adjustment, 1-year mortality was higher among those who initiated dialysis while inpatients (hazard ratio, 2.17; 62.2%), had any activity of daily living dependence prior to dialysis (HR, 1.88; 73.0%), or had more than four comorbidities (HR, 1.5; 59.9%).

Bottom line: Medicare beneficiaries may have significantly higher mortality after initiating dialysis than prior data suggest.

Citation: Wachterman MW et al. One-year mortality after dialysis initiation among older adults. JAMA Intern Med. 2019 Apr 22. doi: 10.1001/jamainternmed.2019.0125.

Dr. Lublin is a hospitalist at the University of Colorado at Denver, Aurora.

Background: The United States Renal Data System registry estimates that approximately 30% of patients die within 1 year of initiating hemodialysis.

Study design: Retrospective, observational analysis.

Setting: The Health and Retirement Study is a nationally representative survey of Medicare beneficiaries during 1998-2014. Medicare claims were linked to mortality data from the National Death Index.

Synopsis: Among 391 patients who initiated dialysis, 22.5%, 44.2%, and 54.5% died within 30 days, 6 months, and 1 year, respectively. After multivariate adjustment, 1-year mortality was higher among those who initiated dialysis while inpatients (hazard ratio, 2.17; 62.2%), had any activity of daily living dependence prior to dialysis (HR, 1.88; 73.0%), or had more than four comorbidities (HR, 1.5; 59.9%).

Bottom line: Medicare beneficiaries may have significantly higher mortality after initiating dialysis than prior data suggest.

Citation: Wachterman MW et al. One-year mortality after dialysis initiation among older adults. JAMA Intern Med. 2019 Apr 22. doi: 10.1001/jamainternmed.2019.0125.

Dr. Lublin is a hospitalist at the University of Colorado at Denver, Aurora.

Background: The United States Renal Data System registry estimates that approximately 30% of patients die within 1 year of initiating hemodialysis.

Study design: Retrospective, observational analysis.

Setting: The Health and Retirement Study is a nationally representative survey of Medicare beneficiaries during 1998-2014. Medicare claims were linked to mortality data from the National Death Index.

Synopsis: Among 391 patients who initiated dialysis, 22.5%, 44.2%, and 54.5% died within 30 days, 6 months, and 1 year, respectively. After multivariate adjustment, 1-year mortality was higher among those who initiated dialysis while inpatients (hazard ratio, 2.17; 62.2%), had any activity of daily living dependence prior to dialysis (HR, 1.88; 73.0%), or had more than four comorbidities (HR, 1.5; 59.9%).

Bottom line: Medicare beneficiaries may have significantly higher mortality after initiating dialysis than prior data suggest.

Citation: Wachterman MW et al. One-year mortality after dialysis initiation among older adults. JAMA Intern Med. 2019 Apr 22. doi: 10.1001/jamainternmed.2019.0125.

Dr. Lublin is a hospitalist at the University of Colorado at Denver, Aurora.

Clinical question: What percent of inpatient health care spending by hospitalists can be attributed to defensive medicine?

Background: Defensive medicine contributes an estimated $45 billion to annual U.S. health care expenditures. The prevalence of defensive medicine among hospitalists is unknown.

Study design: Survey of U.S.-based hospitalists.

Setting: National survey sent to 1,753 hospitalists from all 50 states identified through the Society of Hospital Medicine database of members and meeting attendees.

Synopsis: The survey contained two primary topics: an estimation of defensive spending and liability history. The hospitalists, who had an average of 11 years in practice, completed 1,020 surveys. Participants estimated that defensive medicine accounted for 37.5% of all health care costs. Decreased estimate rates were seen among VA hospitalists (5.5% less), male respondents (36.4% vs. 39.4% for female), non-Hispanic white respondents (32.5% vs. 44.7% for other) and having more years in practice (decrease of 3% for every 10 years in practice). One in four respondents reported being sued at least once, with higher risk seen in those with greater years in practice. There was no association between liability experience and perception of defensive medicine spending. Differences between academic and community settings were not addressed. Because only 30% of practicing hospitalists are members of SHM, it may be difficult to generalize these findings.

Bottom line: Hospitalists perceive that defensive medicine is a major contributor to inpatient health care expenditures.

Citation: Saint S et al. Perception of resources spent on defensive medicine and history of being sued among hospitalists: Results from a national survey. J Hosp Med. 2017 Aug 23. doi: 10.12788/jhm.2800.

Dr. Lublin is a hospitalist at the University of Colorado School of Medicine.

Clinical question: What percent of inpatient health care spending by hospitalists can be attributed to defensive medicine?

Background: Defensive medicine contributes an estimated $45 billion to annual U.S. health care expenditures. The prevalence of defensive medicine among hospitalists is unknown.

Study design: Survey of U.S.-based hospitalists.

Setting: National survey sent to 1,753 hospitalists from all 50 states identified through the Society of Hospital Medicine database of members and meeting attendees.

Synopsis: The survey contained two primary topics: an estimation of defensive spending and liability history. The hospitalists, who had an average of 11 years in practice, completed 1,020 surveys. Participants estimated that defensive medicine accounted for 37.5% of all health care costs. Decreased estimate rates were seen among VA hospitalists (5.5% less), male respondents (36.4% vs. 39.4% for female), non-Hispanic white respondents (32.5% vs. 44.7% for other) and having more years in practice (decrease of 3% for every 10 years in practice). One in four respondents reported being sued at least once, with higher risk seen in those with greater years in practice. There was no association between liability experience and perception of defensive medicine spending. Differences between academic and community settings were not addressed. Because only 30% of practicing hospitalists are members of SHM, it may be difficult to generalize these findings.

Bottom line: Hospitalists perceive that defensive medicine is a major contributor to inpatient health care expenditures.

Citation: Saint S et al. Perception of resources spent on defensive medicine and history of being sued among hospitalists: Results from a national survey. J Hosp Med. 2017 Aug 23. doi: 10.12788/jhm.2800.

Dr. Lublin is a hospitalist at the University of Colorado School of Medicine.

Clinical question: What percent of inpatient health care spending by hospitalists can be attributed to defensive medicine?

Background: Defensive medicine contributes an estimated $45 billion to annual U.S. health care expenditures. The prevalence of defensive medicine among hospitalists is unknown.

Study design: Survey of U.S.-based hospitalists.

Setting: National survey sent to 1,753 hospitalists from all 50 states identified through the Society of Hospital Medicine database of members and meeting attendees.

Synopsis: The survey contained two primary topics: an estimation of defensive spending and liability history. The hospitalists, who had an average of 11 years in practice, completed 1,020 surveys. Participants estimated that defensive medicine accounted for 37.5% of all health care costs. Decreased estimate rates were seen among VA hospitalists (5.5% less), male respondents (36.4% vs. 39.4% for female), non-Hispanic white respondents (32.5% vs. 44.7% for other) and having more years in practice (decrease of 3% for every 10 years in practice). One in four respondents reported being sued at least once, with higher risk seen in those with greater years in practice. There was no association between liability experience and perception of defensive medicine spending. Differences between academic and community settings were not addressed. Because only 30% of practicing hospitalists are members of SHM, it may be difficult to generalize these findings.

Bottom line: Hospitalists perceive that defensive medicine is a major contributor to inpatient health care expenditures.

Citation: Saint S et al. Perception of resources spent on defensive medicine and history of being sued among hospitalists: Results from a national survey. J Hosp Med. 2017 Aug 23. doi: 10.12788/jhm.2800.

Dr. Lublin is a hospitalist at the University of Colorado School of Medicine.

 

Clinical question: Does cost messaging at the time of ordering reduce prescriber use of high-cost medications?

Background: Overprescribing expensive medications contributes to inpatient health care expenditures and may be avoidable when low-cost alternatives are available.

Study design: Retrospective, observational analysis of a quality improvement project.

Setting: Single center, 1,145-bed, tertiary-care academic medical center.

Synopsis: Nine medications were chosen by committee to be targeted for intervention: intravenous voriconazole, IV levetiracetam, IV levothyroxine, IV linezolid, IV eculizumab, IV pantoprazole, IV calcitonin, inhaled ribavirin, and IV mycophenolate. The costs for these nine medications plus lower-cost alternatives were displayed for providers in the order entry system after about 2 years of baseline data had been collected. There was no change in the number of orders or ordering trends for eight of the nine high-cost medications after the intervention. Only ribavirin was ordered less after cost messaging was implemented (16.3 fewer orders per 10,000 patient-days). Lower IV pantoprazole use (73% reduction), correlated with a national shortage unrelated to the study intervention, a potential confounder. Data on dosing frequency and duration were not collected.

Bottom line: Displaying medication costs and alternatives did not alter the use of these nine high-cost medications.

Citation: Conway SJ et al. Impact of displaying inpatient pharmaceutical costs at the time of order entry: Lessons from a tertiary care center. J Hosp Med. 2017 Aug;12(8):639-45.

Dr. Lublin is a hospitalist at the University of Colorado School of Medicine.

 

Clinical question: Does cost messaging at the time of ordering reduce prescriber use of high-cost medications?

Background: Overprescribing expensive medications contributes to inpatient health care expenditures and may be avoidable when low-cost alternatives are available.

Study design: Retrospective, observational analysis of a quality improvement project.

Setting: Single center, 1,145-bed, tertiary-care academic medical center.

Synopsis: Nine medications were chosen by committee to be targeted for intervention: intravenous voriconazole, IV levetiracetam, IV levothyroxine, IV linezolid, IV eculizumab, IV pantoprazole, IV calcitonin, inhaled ribavirin, and IV mycophenolate. The costs for these nine medications plus lower-cost alternatives were displayed for providers in the order entry system after about 2 years of baseline data had been collected. There was no change in the number of orders or ordering trends for eight of the nine high-cost medications after the intervention. Only ribavirin was ordered less after cost messaging was implemented (16.3 fewer orders per 10,000 patient-days). Lower IV pantoprazole use (73% reduction), correlated with a national shortage unrelated to the study intervention, a potential confounder. Data on dosing frequency and duration were not collected.

Bottom line: Displaying medication costs and alternatives did not alter the use of these nine high-cost medications.

Citation: Conway SJ et al. Impact of displaying inpatient pharmaceutical costs at the time of order entry: Lessons from a tertiary care center. J Hosp Med. 2017 Aug;12(8):639-45.

Dr. Lublin is a hospitalist at the University of Colorado School of Medicine.

 

Clinical question: Does cost messaging at the time of ordering reduce prescriber use of high-cost medications?

Background: Overprescribing expensive medications contributes to inpatient health care expenditures and may be avoidable when low-cost alternatives are available.

Study design: Retrospective, observational analysis of a quality improvement project.

Setting: Single center, 1,145-bed, tertiary-care academic medical center.

Synopsis: Nine medications were chosen by committee to be targeted for intervention: intravenous voriconazole, IV levetiracetam, IV levothyroxine, IV linezolid, IV eculizumab, IV pantoprazole, IV calcitonin, inhaled ribavirin, and IV mycophenolate. The costs for these nine medications plus lower-cost alternatives were displayed for providers in the order entry system after about 2 years of baseline data had been collected. There was no change in the number of orders or ordering trends for eight of the nine high-cost medications after the intervention. Only ribavirin was ordered less after cost messaging was implemented (16.3 fewer orders per 10,000 patient-days). Lower IV pantoprazole use (73% reduction), correlated with a national shortage unrelated to the study intervention, a potential confounder. Data on dosing frequency and duration were not collected.

Bottom line: Displaying medication costs and alternatives did not alter the use of these nine high-cost medications.

Citation: Conway SJ et al. Impact of displaying inpatient pharmaceutical costs at the time of order entry: Lessons from a tertiary care center. J Hosp Med. 2017 Aug;12(8):639-45.

Dr. Lublin is a hospitalist at the University of Colorado School of Medicine.