Sherry Boschert

SAN DIEGO – Statins may reduce mortality after pneumonia, but this possible benefit may weaken or disappear in important subgroups of patients, results of a double meta-analysis suggest.

The analyses of data from 13 studies including 254,950 adults with pneumonia found a significant 38% decreased likelihood of dying in patients who were on statins compared with non-statin users, before adjusting for confounding factors, Dr. Vineet Chopra and his associates reported at the annual meeting of the Society of Hospital Medicine.

The investigators then pooled adjusted data from the studies accounting for the effects of various confounders, and found a combined reduction in the risk for death after pneumonia of 34% in statin users compared with nonusers, which also was statistically significant, said Dr. Chopra, a hospitalist at the University of Michigan, Ann Arbor.

He and his associates took it a step further, however, and conducted their own subgroup analyses of the studies’ data because of the heterogeneity of the studies and their patient populations, and because most studies used administrative data sets, which often don’t include the severity of illness and other important factors influencing mortality from pneumonia. Authors of 7 of the 13 studies provided unpublished data.

The subgroup analyses done by Dr. Chopra and his colleagues adjusted for the effects of smoking, vaccination status, severity of pneumonia, and whether the studies featured a score for the propensity of a patient to receive statins. They also looked at whether the studies included "uncommon covariates" such as time to antibiotic delivery, the presence of bacteremia, the presence of advance directives, the use of home health services, residence in a nursing home, and measures of frailty other than comorbidity indices.

"When we started teasing out from each model whether or not they adjusted for" any of these potential confounders and pooled the effects separately for each confounder, "any effect of statin use on mortality after pneumonia was completely eliminated," Dr. Chopra said.

A randomized controlled trial will be needed to understand the effects of statins on outcomes in patients with pneumonia, he said. The findings of the current meta-analyses are to be published in the American Journal of Medicine in October, he added.

The meta-analyses included 10 cohort studies (7 retrospective and 3 prospective), 2 case-control studies, and 1 randomized controlled trial published only as an abstract by Korean investigators who did not respond to requests for more information. "I have some doubts about this study," Dr. Chopra said.

The smallest study included 67 patients, and the largest had 121,254 patients. ("This is a nightmare to deal with" in a meta-analysis, he said.) Eight studies focused on hospitalized patients and five on outpatients. Four studies reported only in-hospital mortality, six reported 30-day mortality, two reported 60-day mortality, and one reported mortality 6 months after pneumonia diagnosis.

The variety in study designs and models limits the significance of the meta-analyses’ findings. The observational nature of meta-analyses and the source of data being observational studies also were limitations. In addition, restrictive inclusion criteria were a constraint: The meta-analyses excluded studies of influenza or ventilator-associated pneumonia because the investigators "wanted a pure cohort of community-acquired pneumonia," he said. Sepsis studies in which mortality could not be linked directly to pneumonia also were excluded.

Pneumonia is the eighth-leading cause of death in hospitalized patients. For hospitalists, "pneumonia is our bread and butter," Dr. Chopra said.

The advent of antibiotics greatly reduced mortality from pneumonia, but the drugs have nearly no effect on mortality in the first 5 days of treatment, he said. Sixty-six percent of deaths from pneumonia happen within 7 days of illness.

Inflammation may be an important factor. A recent study found a 15% reduction in the probability of hospital-acquired pneumonia after chest trauma if patients received hydrocortisone therapy (JAMA 2011;305:1242-3).

Statins have anti-inflammatory properties, and several recent studies have reported that statin users had lower risks of developing pneumonia or complications of pneumonia, or of dying of pneumonia (Respir. Res. 2005;6:82; Chest 2007;131:1006-12; Am. J. Med. 2008;121:1002-7; Pharmacoepidemiol. Drug Saf. 2009;18:697-703).

One study of 8,652 veterans found a 46% lower risk of 30-day mortality after pneumonia in statin users compared with nonusers (Eur. Respir. J. 2008;31:611-7).

Some experts have argued that these perceived benefits could all be due to confounding factors and methodological constraints in the studies, prompting the current study.

Dr. Chopra reported having no financial disclosures.

SAN DIEGO – Statins may reduce mortality after pneumonia, but this possible benefit may weaken or disappear in important subgroups of patients, results of a double meta-analysis suggest.

The analyses of data from 13 studies including 254,950 adults with pneumonia found a significant 38% decreased likelihood of dying in patients who were on statins compared with non-statin users, before adjusting for confounding factors, Dr. Vineet Chopra and his associates reported at the annual meeting of the Society of Hospital Medicine.

The investigators then pooled adjusted data from the studies accounting for the effects of various confounders, and found a combined reduction in the risk for death after pneumonia of 34% in statin users compared with nonusers, which also was statistically significant, said Dr. Chopra, a hospitalist at the University of Michigan, Ann Arbor.

He and his associates took it a step further, however, and conducted their own subgroup analyses of the studies’ data because of the heterogeneity of the studies and their patient populations, and because most studies used administrative data sets, which often don’t include the severity of illness and other important factors influencing mortality from pneumonia. Authors of 7 of the 13 studies provided unpublished data.

The subgroup analyses done by Dr. Chopra and his colleagues adjusted for the effects of smoking, vaccination status, severity of pneumonia, and whether the studies featured a score for the propensity of a patient to receive statins. They also looked at whether the studies included "uncommon covariates" such as time to antibiotic delivery, the presence of bacteremia, the presence of advance directives, the use of home health services, residence in a nursing home, and measures of frailty other than comorbidity indices.

"When we started teasing out from each model whether or not they adjusted for" any of these potential confounders and pooled the effects separately for each confounder, "any effect of statin use on mortality after pneumonia was completely eliminated," Dr. Chopra said.

A randomized controlled trial will be needed to understand the effects of statins on outcomes in patients with pneumonia, he said. The findings of the current meta-analyses are to be published in the American Journal of Medicine in October, he added.

The meta-analyses included 10 cohort studies (7 retrospective and 3 prospective), 2 case-control studies, and 1 randomized controlled trial published only as an abstract by Korean investigators who did not respond to requests for more information. "I have some doubts about this study," Dr. Chopra said.

The smallest study included 67 patients, and the largest had 121,254 patients. ("This is a nightmare to deal with" in a meta-analysis, he said.) Eight studies focused on hospitalized patients and five on outpatients. Four studies reported only in-hospital mortality, six reported 30-day mortality, two reported 60-day mortality, and one reported mortality 6 months after pneumonia diagnosis.

The variety in study designs and models limits the significance of the meta-analyses’ findings. The observational nature of meta-analyses and the source of data being observational studies also were limitations. In addition, restrictive inclusion criteria were a constraint: The meta-analyses excluded studies of influenza or ventilator-associated pneumonia because the investigators "wanted a pure cohort of community-acquired pneumonia," he said. Sepsis studies in which mortality could not be linked directly to pneumonia also were excluded.

Pneumonia is the eighth-leading cause of death in hospitalized patients. For hospitalists, "pneumonia is our bread and butter," Dr. Chopra said.

The advent of antibiotics greatly reduced mortality from pneumonia, but the drugs have nearly no effect on mortality in the first 5 days of treatment, he said. Sixty-six percent of deaths from pneumonia happen within 7 days of illness.

Inflammation may be an important factor. A recent study found a 15% reduction in the probability of hospital-acquired pneumonia after chest trauma if patients received hydrocortisone therapy (JAMA 2011;305:1242-3).

Statins have anti-inflammatory properties, and several recent studies have reported that statin users had lower risks of developing pneumonia or complications of pneumonia, or of dying of pneumonia (Respir. Res. 2005;6:82; Chest 2007;131:1006-12; Am. J. Med. 2008;121:1002-7; Pharmacoepidemiol. Drug Saf. 2009;18:697-703).

One study of 8,652 veterans found a 46% lower risk of 30-day mortality after pneumonia in statin users compared with nonusers (Eur. Respir. J. 2008;31:611-7).

Some experts have argued that these perceived benefits could all be due to confounding factors and methodological constraints in the studies, prompting the current study.

Dr. Chopra reported having no financial disclosures.

SAN DIEGO – Statins may reduce mortality after pneumonia, but this possible benefit may weaken or disappear in important subgroups of patients, results of a double meta-analysis suggest.

The analyses of data from 13 studies including 254,950 adults with pneumonia found a significant 38% decreased likelihood of dying in patients who were on statins compared with non-statin users, before adjusting for confounding factors, Dr. Vineet Chopra and his associates reported at the annual meeting of the Society of Hospital Medicine.

The investigators then pooled adjusted data from the studies accounting for the effects of various confounders, and found a combined reduction in the risk for death after pneumonia of 34% in statin users compared with nonusers, which also was statistically significant, said Dr. Chopra, a hospitalist at the University of Michigan, Ann Arbor.

He and his associates took it a step further, however, and conducted their own subgroup analyses of the studies’ data because of the heterogeneity of the studies and their patient populations, and because most studies used administrative data sets, which often don’t include the severity of illness and other important factors influencing mortality from pneumonia. Authors of 7 of the 13 studies provided unpublished data.

The subgroup analyses done by Dr. Chopra and his colleagues adjusted for the effects of smoking, vaccination status, severity of pneumonia, and whether the studies featured a score for the propensity of a patient to receive statins. They also looked at whether the studies included "uncommon covariates" such as time to antibiotic delivery, the presence of bacteremia, the presence of advance directives, the use of home health services, residence in a nursing home, and measures of frailty other than comorbidity indices.

"When we started teasing out from each model whether or not they adjusted for" any of these potential confounders and pooled the effects separately for each confounder, "any effect of statin use on mortality after pneumonia was completely eliminated," Dr. Chopra said.

A randomized controlled trial will be needed to understand the effects of statins on outcomes in patients with pneumonia, he said. The findings of the current meta-analyses are to be published in the American Journal of Medicine in October, he added.

The meta-analyses included 10 cohort studies (7 retrospective and 3 prospective), 2 case-control studies, and 1 randomized controlled trial published only as an abstract by Korean investigators who did not respond to requests for more information. "I have some doubts about this study," Dr. Chopra said.

The smallest study included 67 patients, and the largest had 121,254 patients. ("This is a nightmare to deal with" in a meta-analysis, he said.) Eight studies focused on hospitalized patients and five on outpatients. Four studies reported only in-hospital mortality, six reported 30-day mortality, two reported 60-day mortality, and one reported mortality 6 months after pneumonia diagnosis.

The variety in study designs and models limits the significance of the meta-analyses’ findings. The observational nature of meta-analyses and the source of data being observational studies also were limitations. In addition, restrictive inclusion criteria were a constraint: The meta-analyses excluded studies of influenza or ventilator-associated pneumonia because the investigators "wanted a pure cohort of community-acquired pneumonia," he said. Sepsis studies in which mortality could not be linked directly to pneumonia also were excluded.

Pneumonia is the eighth-leading cause of death in hospitalized patients. For hospitalists, "pneumonia is our bread and butter," Dr. Chopra said.

The advent of antibiotics greatly reduced mortality from pneumonia, but the drugs have nearly no effect on mortality in the first 5 days of treatment, he said. Sixty-six percent of deaths from pneumonia happen within 7 days of illness.

Inflammation may be an important factor. A recent study found a 15% reduction in the probability of hospital-acquired pneumonia after chest trauma if patients received hydrocortisone therapy (JAMA 2011;305:1242-3).

Statins have anti-inflammatory properties, and several recent studies have reported that statin users had lower risks of developing pneumonia or complications of pneumonia, or of dying of pneumonia (Respir. Res. 2005;6:82; Chest 2007;131:1006-12; Am. J. Med. 2008;121:1002-7; Pharmacoepidemiol. Drug Saf. 2009;18:697-703).

One study of 8,652 veterans found a 46% lower risk of 30-day mortality after pneumonia in statin users compared with nonusers (Eur. Respir. J. 2008;31:611-7).

Some experts have argued that these perceived benefits could all be due to confounding factors and methodological constraints in the studies, prompting the current study.

Dr. Chopra reported having no financial disclosures.

SAN DIEGO – Nearly 70% of patients readmitted within 30 days of discharge from a hospital were patients who had "serial readmissions" during a 6-month period, a study of 82 readmissions among 75 patients found.

Interviews with the patients and medical staff suggest that a portion of both "isolated readmissions" and "serial readmissions" were due to events that might be amenable to simple interventions, but the patients who have serial readmissions tend to have serious medical or social problems that may need complex interventions to reduce readmission rates, Dr. Romsai T. Boonyasai and his associates reported at the annual meeting of the Society of Hospital Medicine.

His study was honored by the society as one of the best three presented at the meeting.

The investigators identified patients who were readmitted within 30 days of discharge from a hospitalist service at a 365-bed teaching hospital in the first 3 months of 2011. They interviewed the patients within 24 hours of readmission, shared the patients’ responses with the hospitalists, and surveyed the hospitalists on whether the readmissions were preventable. The researchers then followed the patients for 6 months to differentiate isolated readmissions from serial readmissions, defined as two or more readmissions during those 6 months.

Among the 52 patients with serial readmissions (69%), 17 were rehospitalized twice (33%), 14 were readmitted three times (27%), 10 returned four times (19%), 3 had five readmissions (6%), 4 had six readmissions (8%), and 4 others were readmitted 10 or more times (8%), said Dr. Boonyasai of Johns Hopkins University, Baltimore.

Forty patients in the entire cohort were female (53%), and patients had a mean age of 60 years. A median of 14 days elapsed between discharge and readmission. Forty-three patients said they had felt "ready to leave" the hospital at the time of the initial discharge (57%), and 51 patients (68%) rated the initial admission as "patient-centered."

After the hospitalists had a chance to reflect on these cases and patients’ responses, the investigators identified several themes among the readmissions, Dr. Boonyasai said.

Some rehospitalizations were planned in both the "isolated" and "serial" readmission groups, such as the readmission of a 32-year-old woman who needed to have ureteral stents removed. Patients in both groups also experienced unexpected or adverse events after discharge, such as a 79-year-old man who slipped on a curb as he was getting into a taxi while leaving a rehabilitation facility.

Among patients with serial readmissions, however, rehospitalizations seemed to be caused by the patients’ nonadherence to the plan for care, advanced or chronic diseases, or a need for postdischarge care, Dr. Boonyasai said.

One 61-year-old woman who had a pattern of ignoring physicians’ recommendations continued to smoke despite nonsmoking policies at nursing homes and occasionally abused alcohol or other substances against recommendations. She was readmitted twice in 6 months.

Among patients with advanced or chronic disease, a steroid-dependent 68-year-old woman was readmitted six times in 6 months (and 12 times over a 12-month period) for frequent exacerbations of chronic obstructive pulmonary disease. A 67-year-old man with recurrent cancer had two readmissions in 6 months and was likely to have more. A 38-year-old man whose substance abuse problems were not under control was readmitted 12 times in 6 months, and rehospitalizations were likely to continue until the core problem was under control.

A 68-year-old woman who was readmitted six times in 6 months provided an example of the need for postdischarge care. The hospitalists felt that her readmissions were preventable if she had a good discharge plan that involved responsive outpatient health care providers. The patient was considered to have very low self-efficacy, and she felt isolated from her care providers. If her primary physician, insurer, and home-care resources could be brought together, a care plan could be crafted for her "to seek help when things start to go south (typically after 3 or 4 days)," one hospitalist wrote.

Dr. Boonyasai said that his personal conclusion from the study is that "really sick patients keep coming back a lot." His next step will be to investigate what it means to have complex interventions for these patients.

Dr. Boonyasai’s hospitalist colleagues suggested several interventions to reduce readmissions, he added, including "shadowing" patients at home, visiting the nursing homes from which patients get rehospitalized, teaching techniques for motivational interviewing to hospitalists, and creating a better process for having early discussions with patients about palliative care.

In general, about 25% of physicians learn that patients they discharged have been rehospitalized, which means opportunities to learn from these cases are being missed, Dr. Boonyasai said. The researchers tried to shed some light on patient subpopulations among early readmissions, a topic that has not been well understood.

The findings were limited by the small size of the study; drawing data from a single institution, with possible recall bias in interview responses; and the possibility that responses were modified to meet socially desirable expectations.

Dr. Boonyasai reported having no financial disclosures.

SAN DIEGO – Nearly 70% of patients readmitted within 30 days of discharge from a hospital were patients who had "serial readmissions" during a 6-month period, a study of 82 readmissions among 75 patients found.

Interviews with the patients and medical staff suggest that a portion of both "isolated readmissions" and "serial readmissions" were due to events that might be amenable to simple interventions, but the patients who have serial readmissions tend to have serious medical or social problems that may need complex interventions to reduce readmission rates, Dr. Romsai T. Boonyasai and his associates reported at the annual meeting of the Society of Hospital Medicine.

His study was honored by the society as one of the best three presented at the meeting.

The investigators identified patients who were readmitted within 30 days of discharge from a hospitalist service at a 365-bed teaching hospital in the first 3 months of 2011. They interviewed the patients within 24 hours of readmission, shared the patients’ responses with the hospitalists, and surveyed the hospitalists on whether the readmissions were preventable. The researchers then followed the patients for 6 months to differentiate isolated readmissions from serial readmissions, defined as two or more readmissions during those 6 months.

Among the 52 patients with serial readmissions (69%), 17 were rehospitalized twice (33%), 14 were readmitted three times (27%), 10 returned four times (19%), 3 had five readmissions (6%), 4 had six readmissions (8%), and 4 others were readmitted 10 or more times (8%), said Dr. Boonyasai of Johns Hopkins University, Baltimore.

Forty patients in the entire cohort were female (53%), and patients had a mean age of 60 years. A median of 14 days elapsed between discharge and readmission. Forty-three patients said they had felt "ready to leave" the hospital at the time of the initial discharge (57%), and 51 patients (68%) rated the initial admission as "patient-centered."

After the hospitalists had a chance to reflect on these cases and patients’ responses, the investigators identified several themes among the readmissions, Dr. Boonyasai said.

Some rehospitalizations were planned in both the "isolated" and "serial" readmission groups, such as the readmission of a 32-year-old woman who needed to have ureteral stents removed. Patients in both groups also experienced unexpected or adverse events after discharge, such as a 79-year-old man who slipped on a curb as he was getting into a taxi while leaving a rehabilitation facility.

Among patients with serial readmissions, however, rehospitalizations seemed to be caused by the patients’ nonadherence to the plan for care, advanced or chronic diseases, or a need for postdischarge care, Dr. Boonyasai said.

One 61-year-old woman who had a pattern of ignoring physicians’ recommendations continued to smoke despite nonsmoking policies at nursing homes and occasionally abused alcohol or other substances against recommendations. She was readmitted twice in 6 months.

Among patients with advanced or chronic disease, a steroid-dependent 68-year-old woman was readmitted six times in 6 months (and 12 times over a 12-month period) for frequent exacerbations of chronic obstructive pulmonary disease. A 67-year-old man with recurrent cancer had two readmissions in 6 months and was likely to have more. A 38-year-old man whose substance abuse problems were not under control was readmitted 12 times in 6 months, and rehospitalizations were likely to continue until the core problem was under control.

A 68-year-old woman who was readmitted six times in 6 months provided an example of the need for postdischarge care. The hospitalists felt that her readmissions were preventable if she had a good discharge plan that involved responsive outpatient health care providers. The patient was considered to have very low self-efficacy, and she felt isolated from her care providers. If her primary physician, insurer, and home-care resources could be brought together, a care plan could be crafted for her "to seek help when things start to go south (typically after 3 or 4 days)," one hospitalist wrote.

Dr. Boonyasai said that his personal conclusion from the study is that "really sick patients keep coming back a lot." His next step will be to investigate what it means to have complex interventions for these patients.

Dr. Boonyasai’s hospitalist colleagues suggested several interventions to reduce readmissions, he added, including "shadowing" patients at home, visiting the nursing homes from which patients get rehospitalized, teaching techniques for motivational interviewing to hospitalists, and creating a better process for having early discussions with patients about palliative care.

In general, about 25% of physicians learn that patients they discharged have been rehospitalized, which means opportunities to learn from these cases are being missed, Dr. Boonyasai said. The researchers tried to shed some light on patient subpopulations among early readmissions, a topic that has not been well understood.

The findings were limited by the small size of the study; drawing data from a single institution, with possible recall bias in interview responses; and the possibility that responses were modified to meet socially desirable expectations.

Dr. Boonyasai reported having no financial disclosures.

SAN DIEGO – Nearly 70% of patients readmitted within 30 days of discharge from a hospital were patients who had "serial readmissions" during a 6-month period, a study of 82 readmissions among 75 patients found.

Interviews with the patients and medical staff suggest that a portion of both "isolated readmissions" and "serial readmissions" were due to events that might be amenable to simple interventions, but the patients who have serial readmissions tend to have serious medical or social problems that may need complex interventions to reduce readmission rates, Dr. Romsai T. Boonyasai and his associates reported at the annual meeting of the Society of Hospital Medicine.

His study was honored by the society as one of the best three presented at the meeting.

The investigators identified patients who were readmitted within 30 days of discharge from a hospitalist service at a 365-bed teaching hospital in the first 3 months of 2011. They interviewed the patients within 24 hours of readmission, shared the patients’ responses with the hospitalists, and surveyed the hospitalists on whether the readmissions were preventable. The researchers then followed the patients for 6 months to differentiate isolated readmissions from serial readmissions, defined as two or more readmissions during those 6 months.

Among the 52 patients with serial readmissions (69%), 17 were rehospitalized twice (33%), 14 were readmitted three times (27%), 10 returned four times (19%), 3 had five readmissions (6%), 4 had six readmissions (8%), and 4 others were readmitted 10 or more times (8%), said Dr. Boonyasai of Johns Hopkins University, Baltimore.

Forty patients in the entire cohort were female (53%), and patients had a mean age of 60 years. A median of 14 days elapsed between discharge and readmission. Forty-three patients said they had felt "ready to leave" the hospital at the time of the initial discharge (57%), and 51 patients (68%) rated the initial admission as "patient-centered."

After the hospitalists had a chance to reflect on these cases and patients’ responses, the investigators identified several themes among the readmissions, Dr. Boonyasai said.

Some rehospitalizations were planned in both the "isolated" and "serial" readmission groups, such as the readmission of a 32-year-old woman who needed to have ureteral stents removed. Patients in both groups also experienced unexpected or adverse events after discharge, such as a 79-year-old man who slipped on a curb as he was getting into a taxi while leaving a rehabilitation facility.

Among patients with serial readmissions, however, rehospitalizations seemed to be caused by the patients’ nonadherence to the plan for care, advanced or chronic diseases, or a need for postdischarge care, Dr. Boonyasai said.

One 61-year-old woman who had a pattern of ignoring physicians’ recommendations continued to smoke despite nonsmoking policies at nursing homes and occasionally abused alcohol or other substances against recommendations. She was readmitted twice in 6 months.

Among patients with advanced or chronic disease, a steroid-dependent 68-year-old woman was readmitted six times in 6 months (and 12 times over a 12-month period) for frequent exacerbations of chronic obstructive pulmonary disease. A 67-year-old man with recurrent cancer had two readmissions in 6 months and was likely to have more. A 38-year-old man whose substance abuse problems were not under control was readmitted 12 times in 6 months, and rehospitalizations were likely to continue until the core problem was under control.

A 68-year-old woman who was readmitted six times in 6 months provided an example of the need for postdischarge care. The hospitalists felt that her readmissions were preventable if she had a good discharge plan that involved responsive outpatient health care providers. The patient was considered to have very low self-efficacy, and she felt isolated from her care providers. If her primary physician, insurer, and home-care resources could be brought together, a care plan could be crafted for her "to seek help when things start to go south (typically after 3 or 4 days)," one hospitalist wrote.

Dr. Boonyasai said that his personal conclusion from the study is that "really sick patients keep coming back a lot." His next step will be to investigate what it means to have complex interventions for these patients.

Dr. Boonyasai’s hospitalist colleagues suggested several interventions to reduce readmissions, he added, including "shadowing" patients at home, visiting the nursing homes from which patients get rehospitalized, teaching techniques for motivational interviewing to hospitalists, and creating a better process for having early discussions with patients about palliative care.

In general, about 25% of physicians learn that patients they discharged have been rehospitalized, which means opportunities to learn from these cases are being missed, Dr. Boonyasai said. The researchers tried to shed some light on patient subpopulations among early readmissions, a topic that has not been well understood.

The findings were limited by the small size of the study; drawing data from a single institution, with possible recall bias in interview responses; and the possibility that responses were modified to meet socially desirable expectations.

Dr. Boonyasai reported having no financial disclosures.

SAN DIEGO – Giving acetaminophen to patients who reported consuming ethanol did not adversely affect markers of liver damage in a meta-analysis of randomized, controlled trials.

"One of the questions we often get asked is the role of acetaminophen in patients with liver disease," said Dr. Kennon J. Heard, an emergency medicine physician at the University of Colorado and director of the Medical Toxicology Fellowship at the Rocky Mountain Poison and Drug Center, Denver.

The findings of the meta-analysis suggest that "acetaminophen is safe in alcoholics," he said at the annual meeting of the Society of Hospital Medicine.

The meta-analysis included five trials involving 901 subjects (including patients who reported drinking ethanol) who were randomized to receive acetaminophen or placebo. Dr. Heard and his associates looked at daily ALT measurements out to a mean of 4 days, a time period for which most of the studies had data. They also looked for any evidence of liver injury or dysfunction, hepatotoxicity, or death.

The alanine aminotransferase (ALT) levels changed by a mean of 0.04 IU/L after starting acetaminophen or placebo, "less than a tenth of a point in ALT," reported Dr. Heard. "Essentially, in this group of patients who consume alcohol, if you give them acetaminophen for 4 days, you don’t see any change in their ALT."

The study is to be published in the journal Pharmacotherapy.

When acetaminophen consumption continued beyond 4 days, ALT levels increased in most patients who consumed alcohol but also increased in 60% of non-drinkers. "The changes in the alcoholics look exactly like the changes in the non-alcoholics," he said. The median increase in ALT was between 10-20 IU/L.

Among patients who drink alcohol, the highest ALT level in the acetaminophen group was 312 IU/L, "which is pretty impressive until you see that in the placebo group, somebody went up 288" IU/L, he said. The biggest increase in ALT was in a healthy nondrinking patient on acetaminophen, whose ALT increased by 638 IU/L.

Most importantly, none of the 551 people who received acetaminophen in those trials developed an increase in International Normalized Ratio, bilirubin level, or symptomatic liver injury, he added.

Dr. Heard and his associates are now finishing a separate study that appears to confirm that these are asymptomatic, self-limiting elevations in ALT that will go away even if people stay on acetaminophen.

"It is worth knowing that if you have someone who has an ALT elevation while taking acetaminophen, it may be the cause, and it is reasonable to stop the acetaminophen and see if their ALT elevations go away rather than do an extensive workup for hepatitis," he said.

Dr. Heard has been a consultant or received research grants from Cadence Pharmaceuticals, McNeil Consumer Healthcare, and Cumberland Pharmaceuticals.

SAN DIEGO – Giving acetaminophen to patients who reported consuming ethanol did not adversely affect markers of liver damage in a meta-analysis of randomized, controlled trials.

"One of the questions we often get asked is the role of acetaminophen in patients with liver disease," said Dr. Kennon J. Heard, an emergency medicine physician at the University of Colorado and director of the Medical Toxicology Fellowship at the Rocky Mountain Poison and Drug Center, Denver.

The findings of the meta-analysis suggest that "acetaminophen is safe in alcoholics," he said at the annual meeting of the Society of Hospital Medicine.

The meta-analysis included five trials involving 901 subjects (including patients who reported drinking ethanol) who were randomized to receive acetaminophen or placebo. Dr. Heard and his associates looked at daily ALT measurements out to a mean of 4 days, a time period for which most of the studies had data. They also looked for any evidence of liver injury or dysfunction, hepatotoxicity, or death.

The alanine aminotransferase (ALT) levels changed by a mean of 0.04 IU/L after starting acetaminophen or placebo, "less than a tenth of a point in ALT," reported Dr. Heard. "Essentially, in this group of patients who consume alcohol, if you give them acetaminophen for 4 days, you don’t see any change in their ALT."

The study is to be published in the journal Pharmacotherapy.

When acetaminophen consumption continued beyond 4 days, ALT levels increased in most patients who consumed alcohol but also increased in 60% of non-drinkers. "The changes in the alcoholics look exactly like the changes in the non-alcoholics," he said. The median increase in ALT was between 10-20 IU/L.

Among patients who drink alcohol, the highest ALT level in the acetaminophen group was 312 IU/L, "which is pretty impressive until you see that in the placebo group, somebody went up 288" IU/L, he said. The biggest increase in ALT was in a healthy nondrinking patient on acetaminophen, whose ALT increased by 638 IU/L.

Most importantly, none of the 551 people who received acetaminophen in those trials developed an increase in International Normalized Ratio, bilirubin level, or symptomatic liver injury, he added.

Dr. Heard and his associates are now finishing a separate study that appears to confirm that these are asymptomatic, self-limiting elevations in ALT that will go away even if people stay on acetaminophen.

"It is worth knowing that if you have someone who has an ALT elevation while taking acetaminophen, it may be the cause, and it is reasonable to stop the acetaminophen and see if their ALT elevations go away rather than do an extensive workup for hepatitis," he said.

Dr. Heard has been a consultant or received research grants from Cadence Pharmaceuticals, McNeil Consumer Healthcare, and Cumberland Pharmaceuticals.

SAN DIEGO – Giving acetaminophen to patients who reported consuming ethanol did not adversely affect markers of liver damage in a meta-analysis of randomized, controlled trials.

"One of the questions we often get asked is the role of acetaminophen in patients with liver disease," said Dr. Kennon J. Heard, an emergency medicine physician at the University of Colorado and director of the Medical Toxicology Fellowship at the Rocky Mountain Poison and Drug Center, Denver.

The findings of the meta-analysis suggest that "acetaminophen is safe in alcoholics," he said at the annual meeting of the Society of Hospital Medicine.

The meta-analysis included five trials involving 901 subjects (including patients who reported drinking ethanol) who were randomized to receive acetaminophen or placebo. Dr. Heard and his associates looked at daily ALT measurements out to a mean of 4 days, a time period for which most of the studies had data. They also looked for any evidence of liver injury or dysfunction, hepatotoxicity, or death.

The alanine aminotransferase (ALT) levels changed by a mean of 0.04 IU/L after starting acetaminophen or placebo, "less than a tenth of a point in ALT," reported Dr. Heard. "Essentially, in this group of patients who consume alcohol, if you give them acetaminophen for 4 days, you don’t see any change in their ALT."

The study is to be published in the journal Pharmacotherapy.

When acetaminophen consumption continued beyond 4 days, ALT levels increased in most patients who consumed alcohol but also increased in 60% of non-drinkers. "The changes in the alcoholics look exactly like the changes in the non-alcoholics," he said. The median increase in ALT was between 10-20 IU/L.

Among patients who drink alcohol, the highest ALT level in the acetaminophen group was 312 IU/L, "which is pretty impressive until you see that in the placebo group, somebody went up 288" IU/L, he said. The biggest increase in ALT was in a healthy nondrinking patient on acetaminophen, whose ALT increased by 638 IU/L.

Most importantly, none of the 551 people who received acetaminophen in those trials developed an increase in International Normalized Ratio, bilirubin level, or symptomatic liver injury, he added.

Dr. Heard and his associates are now finishing a separate study that appears to confirm that these are asymptomatic, self-limiting elevations in ALT that will go away even if people stay on acetaminophen.

"It is worth knowing that if you have someone who has an ALT elevation while taking acetaminophen, it may be the cause, and it is reasonable to stop the acetaminophen and see if their ALT elevations go away rather than do an extensive workup for hepatitis," he said.

Dr. Heard has been a consultant or received research grants from Cadence Pharmaceuticals, McNeil Consumer Healthcare, and Cumberland Pharmaceuticals.

SAN DIEGO – Inappropriate use of bronchodilators to treat pediatric bronchiolitis declined from 70% of patients in 2007 to 58% in 2010, thanks to benchmarking and peer-to-peer collaborative efforts of the Value in Inpatient Pediatrics Network at hospitals in 14 states.

Bronchodilator utilization decreased by 45% as measured by doses per patient, from 7.6 doses/patient in 2007 to 4.2 doses/patient in 2010, Dr. Shawn Ralston and her associates reported at the annual meeting of the Society of Hospital Medicine.

Photo courtesy Dr. Shawn Ralston

Inappropriate use of chest physiotherapy to treat pediatric bronchiolitis also declined, from 14% of cases in 2007 to 4.2% in 2010, said Dr. Ralston, chief of the division of inpatient pediatrics at the University of Texas Health Science Center, San Antonio.

The investigators had hoped to see declines as well in the inappropriate use of chest x-rays, steroids, and testing for respiratory syncytial virus, but mild declines in these categories did not reach statistical significance.

Bronchiolitis is the most common reason for hospitalizing infants and toddlers, with wide variation in care. Practice guidelines from the American Academy of Pediatrics (AAP) in 2006 recommend treating pediatric bronchiolitis with nothing but supportive care. Bronchodilator therapy and steroid therapy have been shown to have no benefit for these cases in repeated meta-analyses over the past 15 and 12 years, respectively.

"None of the things we all do frequently have any support" in the literature for managing pediatric bronchiolitis, Dr. Ralston, a steering committee member of the Value in Inpatient Pediatrics (VIP) Network.

The VIP Network, formed out of an AAP section on hospital medicine, pulled together physicians who were frustrated with the lack of pediatric resources for quality improvement in smaller academic and community hospitals. The VIP Network chose bronchiolitis as its first target to see if it could start to change management by providing a peer group for local leaders to share resources and benchmark progress within the group.

The VIP Network functions as a virtual community with yearly meetings that adopted group norms for appropriate bronchiolitis care. Its website offers handouts, bibliographies, and other resources, and network members provided peer-to-peer coaching on quality improvement.

Members produced yearly benchmarking reports using hospital billing data for diagnostic codes 466.11 or 466.19 starting in 2008 (with some 2007 data serving as additional baseline data). Dr. Ralston said that 90% of data came from non-freestanding children’s facilities. In all, 70% of participating facilities did not have a guideline for pediatric bronchiolitis management prior to joining the Network, Dr. Ralston said. A total of 30% of facilities were in urban locations.

The results show that an all-volunteer group with no source of specific funding and no new resources can make real-world changes that improve the quality of care, she said.

"The caveat is that it has to be something the physicians really care about," she said. "Clinicians are significantly more motivated for this kind of work than researchers."

Dr. Ralston reported having no financial disclosures. She receives funds from the American Academy of Pediatrics to be editor of the journal Hospital Pediatrics.

SAN DIEGO – Inappropriate use of bronchodilators to treat pediatric bronchiolitis declined from 70% of patients in 2007 to 58% in 2010, thanks to benchmarking and peer-to-peer collaborative efforts of the Value in Inpatient Pediatrics Network at hospitals in 14 states.

Bronchodilator utilization decreased by 45% as measured by doses per patient, from 7.6 doses/patient in 2007 to 4.2 doses/patient in 2010, Dr. Shawn Ralston and her associates reported at the annual meeting of the Society of Hospital Medicine.

Photo courtesy Dr. Shawn Ralston

Inappropriate use of chest physiotherapy to treat pediatric bronchiolitis also declined, from 14% of cases in 2007 to 4.2% in 2010, said Dr. Ralston, chief of the division of inpatient pediatrics at the University of Texas Health Science Center, San Antonio.

The investigators had hoped to see declines as well in the inappropriate use of chest x-rays, steroids, and testing for respiratory syncytial virus, but mild declines in these categories did not reach statistical significance.

Bronchiolitis is the most common reason for hospitalizing infants and toddlers, with wide variation in care. Practice guidelines from the American Academy of Pediatrics (AAP) in 2006 recommend treating pediatric bronchiolitis with nothing but supportive care. Bronchodilator therapy and steroid therapy have been shown to have no benefit for these cases in repeated meta-analyses over the past 15 and 12 years, respectively.

"None of the things we all do frequently have any support" in the literature for managing pediatric bronchiolitis, Dr. Ralston, a steering committee member of the Value in Inpatient Pediatrics (VIP) Network.

The VIP Network, formed out of an AAP section on hospital medicine, pulled together physicians who were frustrated with the lack of pediatric resources for quality improvement in smaller academic and community hospitals. The VIP Network chose bronchiolitis as its first target to see if it could start to change management by providing a peer group for local leaders to share resources and benchmark progress within the group.

The VIP Network functions as a virtual community with yearly meetings that adopted group norms for appropriate bronchiolitis care. Its website offers handouts, bibliographies, and other resources, and network members provided peer-to-peer coaching on quality improvement.

Members produced yearly benchmarking reports using hospital billing data for diagnostic codes 466.11 or 466.19 starting in 2008 (with some 2007 data serving as additional baseline data). Dr. Ralston said that 90% of data came from non-freestanding children’s facilities. In all, 70% of participating facilities did not have a guideline for pediatric bronchiolitis management prior to joining the Network, Dr. Ralston said. A total of 30% of facilities were in urban locations.

The results show that an all-volunteer group with no source of specific funding and no new resources can make real-world changes that improve the quality of care, she said.

"The caveat is that it has to be something the physicians really care about," she said. "Clinicians are significantly more motivated for this kind of work than researchers."

Dr. Ralston reported having no financial disclosures. She receives funds from the American Academy of Pediatrics to be editor of the journal Hospital Pediatrics.

SAN DIEGO – Inappropriate use of bronchodilators to treat pediatric bronchiolitis declined from 70% of patients in 2007 to 58% in 2010, thanks to benchmarking and peer-to-peer collaborative efforts of the Value in Inpatient Pediatrics Network at hospitals in 14 states.

Bronchodilator utilization decreased by 45% as measured by doses per patient, from 7.6 doses/patient in 2007 to 4.2 doses/patient in 2010, Dr. Shawn Ralston and her associates reported at the annual meeting of the Society of Hospital Medicine.

Photo courtesy Dr. Shawn Ralston

Inappropriate use of chest physiotherapy to treat pediatric bronchiolitis also declined, from 14% of cases in 2007 to 4.2% in 2010, said Dr. Ralston, chief of the division of inpatient pediatrics at the University of Texas Health Science Center, San Antonio.

The investigators had hoped to see declines as well in the inappropriate use of chest x-rays, steroids, and testing for respiratory syncytial virus, but mild declines in these categories did not reach statistical significance.

Bronchiolitis is the most common reason for hospitalizing infants and toddlers, with wide variation in care. Practice guidelines from the American Academy of Pediatrics (AAP) in 2006 recommend treating pediatric bronchiolitis with nothing but supportive care. Bronchodilator therapy and steroid therapy have been shown to have no benefit for these cases in repeated meta-analyses over the past 15 and 12 years, respectively.

"None of the things we all do frequently have any support" in the literature for managing pediatric bronchiolitis, Dr. Ralston, a steering committee member of the Value in Inpatient Pediatrics (VIP) Network.

The VIP Network, formed out of an AAP section on hospital medicine, pulled together physicians who were frustrated with the lack of pediatric resources for quality improvement in smaller academic and community hospitals. The VIP Network chose bronchiolitis as its first target to see if it could start to change management by providing a peer group for local leaders to share resources and benchmark progress within the group.

The VIP Network functions as a virtual community with yearly meetings that adopted group norms for appropriate bronchiolitis care. Its website offers handouts, bibliographies, and other resources, and network members provided peer-to-peer coaching on quality improvement.

Members produced yearly benchmarking reports using hospital billing data for diagnostic codes 466.11 or 466.19 starting in 2008 (with some 2007 data serving as additional baseline data). Dr. Ralston said that 90% of data came from non-freestanding children’s facilities. In all, 70% of participating facilities did not have a guideline for pediatric bronchiolitis management prior to joining the Network, Dr. Ralston said. A total of 30% of facilities were in urban locations.

The results show that an all-volunteer group with no source of specific funding and no new resources can make real-world changes that improve the quality of care, she said.

"The caveat is that it has to be something the physicians really care about," she said. "Clinicians are significantly more motivated for this kind of work than researchers."

Dr. Ralston reported having no financial disclosures. She receives funds from the American Academy of Pediatrics to be editor of the journal Hospital Pediatrics.

SAN DIEGO – The clock has run out on 20-hour and 72-hour protocols for treating acetaminophen overdose. Clinical end points such as acetaminophen concentration and AST or ALT levels now determine when to end therapy.

In the mid-2000s, a 20-hour protocol for treatment with intravenous acetylcysteine generally replaced the traditional 72-hour protocol for treatment with oral acetylcysteine, but the 20-hour protocol has proved insufficient in rare cases of overdose on very, very large amounts of acetaminophen, Dr. Kennon J. Heard said.

In some of these patients, so much acetaminophen gets stored in the GI tract that the patient continues to absorb acetaminophen during the 20 hours of treatment. If treatment stops at 20 hours, "they’re going to have another overdose. They’re going to go on and get sick," he said at the annual meeting of the Society of Hospital Medicine.

Most toxicologists now prefer to end treatment based on clinical end points instead of time-based protocols. The new approach gets nearly all patients with acetaminophen overdose out of the hospital before 72 hours, and most patients still get treated for only 20 hours, said Dr. Heard, an emergency medicine physician at the University of Colorado and director of the Medical Toxicology Fellowship at the Rocky Mountain Poison and Drug Center, Denver.

Follow serum acetaminophen levels until all of the drug has been metabolized, indicated by serum levels below 10 mg/L or, ideally, undetectable levels. Make sure that markers of liver injury –ALT, (alanine aminotransferase), AST (aspartate aminotransferase) International Normalized Ratio, and creatinine – are improving or at least stable before ending therapy, he advised.

"If their AST or ALT starts out normal and stays normal, you can stop at 20 hours. If the AST or ALT is going up, we like to see it clearly start to go down or at least stabilizing at 20 hours, or sometimes even sooner," he said. "As long as the patient is clinically well, the ALT and AST are improving and they don’t have any acetaminophen on board, you can stop treatment."

In cases of massive overdose, in which the patient presents with a serum acetaminophen level greater than 500 mg/L or has a level greater than 75 mg/L after 20 hours of treatment, consult with your local poison center experts, Dr. Heard added.

Prolonged treatment may be needed, and some experts have suggested giving higher doses of acetylcysteine because the very high levels of acetaminophen may exceed the ability of acetylcysteine to detoxify the patient, he said.

"These cases are rare. We usually have one or two of them a year," Dr. Heard said.

Historically, the 72-hour protocol for treatment with oral acetylcysteine was developed before acetaminophen assays were routinely available in the United States. Patients were hospitalized for 3 days, "drinking stuff that smelled terrible, and generally, it was probably a waste of a lot of resources" because studies have subsequently shown that most patients don’t need 72 hours of treatment, he said.

With oral therapy, it seemed that as long as patients started treatment within 10-20 hours of overdose, they would recover. After development of intravenous acetylcysteine and shortening of the protocol to 20 hours, however, these rare cases of treatment failure began showing up.

Dr. Heard has been a consultant or received research grants from Cadence Pharmaceuticals, McNeil Consumer Healthcare, and Cumberland Pharmaceuticals.

SAN DIEGO – The clock has run out on 20-hour and 72-hour protocols for treating acetaminophen overdose. Clinical end points such as acetaminophen concentration and AST or ALT levels now determine when to end therapy.

In the mid-2000s, a 20-hour protocol for treatment with intravenous acetylcysteine generally replaced the traditional 72-hour protocol for treatment with oral acetylcysteine, but the 20-hour protocol has proved insufficient in rare cases of overdose on very, very large amounts of acetaminophen, Dr. Kennon J. Heard said.

In some of these patients, so much acetaminophen gets stored in the GI tract that the patient continues to absorb acetaminophen during the 20 hours of treatment. If treatment stops at 20 hours, "they’re going to have another overdose. They’re going to go on and get sick," he said at the annual meeting of the Society of Hospital Medicine.

Most toxicologists now prefer to end treatment based on clinical end points instead of time-based protocols. The new approach gets nearly all patients with acetaminophen overdose out of the hospital before 72 hours, and most patients still get treated for only 20 hours, said Dr. Heard, an emergency medicine physician at the University of Colorado and director of the Medical Toxicology Fellowship at the Rocky Mountain Poison and Drug Center, Denver.

Follow serum acetaminophen levels until all of the drug has been metabolized, indicated by serum levels below 10 mg/L or, ideally, undetectable levels. Make sure that markers of liver injury –ALT, (alanine aminotransferase), AST (aspartate aminotransferase) International Normalized Ratio, and creatinine – are improving or at least stable before ending therapy, he advised.

"If their AST or ALT starts out normal and stays normal, you can stop at 20 hours. If the AST or ALT is going up, we like to see it clearly start to go down or at least stabilizing at 20 hours, or sometimes even sooner," he said. "As long as the patient is clinically well, the ALT and AST are improving and they don’t have any acetaminophen on board, you can stop treatment."

In cases of massive overdose, in which the patient presents with a serum acetaminophen level greater than 500 mg/L or has a level greater than 75 mg/L after 20 hours of treatment, consult with your local poison center experts, Dr. Heard added.

Prolonged treatment may be needed, and some experts have suggested giving higher doses of acetylcysteine because the very high levels of acetaminophen may exceed the ability of acetylcysteine to detoxify the patient, he said.

"These cases are rare. We usually have one or two of them a year," Dr. Heard said.

Historically, the 72-hour protocol for treatment with oral acetylcysteine was developed before acetaminophen assays were routinely available in the United States. Patients were hospitalized for 3 days, "drinking stuff that smelled terrible, and generally, it was probably a waste of a lot of resources" because studies have subsequently shown that most patients don’t need 72 hours of treatment, he said.

With oral therapy, it seemed that as long as patients started treatment within 10-20 hours of overdose, they would recover. After development of intravenous acetylcysteine and shortening of the protocol to 20 hours, however, these rare cases of treatment failure began showing up.

Dr. Heard has been a consultant or received research grants from Cadence Pharmaceuticals, McNeil Consumer Healthcare, and Cumberland Pharmaceuticals.

SAN DIEGO – The clock has run out on 20-hour and 72-hour protocols for treating acetaminophen overdose. Clinical end points such as acetaminophen concentration and AST or ALT levels now determine when to end therapy.

In the mid-2000s, a 20-hour protocol for treatment with intravenous acetylcysteine generally replaced the traditional 72-hour protocol for treatment with oral acetylcysteine, but the 20-hour protocol has proved insufficient in rare cases of overdose on very, very large amounts of acetaminophen, Dr. Kennon J. Heard said.

In some of these patients, so much acetaminophen gets stored in the GI tract that the patient continues to absorb acetaminophen during the 20 hours of treatment. If treatment stops at 20 hours, "they’re going to have another overdose. They’re going to go on and get sick," he said at the annual meeting of the Society of Hospital Medicine.

Most toxicologists now prefer to end treatment based on clinical end points instead of time-based protocols. The new approach gets nearly all patients with acetaminophen overdose out of the hospital before 72 hours, and most patients still get treated for only 20 hours, said Dr. Heard, an emergency medicine physician at the University of Colorado and director of the Medical Toxicology Fellowship at the Rocky Mountain Poison and Drug Center, Denver.

Follow serum acetaminophen levels until all of the drug has been metabolized, indicated by serum levels below 10 mg/L or, ideally, undetectable levels. Make sure that markers of liver injury –ALT, (alanine aminotransferase), AST (aspartate aminotransferase) International Normalized Ratio, and creatinine – are improving or at least stable before ending therapy, he advised.

"If their AST or ALT starts out normal and stays normal, you can stop at 20 hours. If the AST or ALT is going up, we like to see it clearly start to go down or at least stabilizing at 20 hours, or sometimes even sooner," he said. "As long as the patient is clinically well, the ALT and AST are improving and they don’t have any acetaminophen on board, you can stop treatment."

In cases of massive overdose, in which the patient presents with a serum acetaminophen level greater than 500 mg/L or has a level greater than 75 mg/L after 20 hours of treatment, consult with your local poison center experts, Dr. Heard added.

Prolonged treatment may be needed, and some experts have suggested giving higher doses of acetylcysteine because the very high levels of acetaminophen may exceed the ability of acetylcysteine to detoxify the patient, he said.

"These cases are rare. We usually have one or two of them a year," Dr. Heard said.

Historically, the 72-hour protocol for treatment with oral acetylcysteine was developed before acetaminophen assays were routinely available in the United States. Patients were hospitalized for 3 days, "drinking stuff that smelled terrible, and generally, it was probably a waste of a lot of resources" because studies have subsequently shown that most patients don’t need 72 hours of treatment, he said.

With oral therapy, it seemed that as long as patients started treatment within 10-20 hours of overdose, they would recover. After development of intravenous acetylcysteine and shortening of the protocol to 20 hours, however, these rare cases of treatment failure began showing up.

Dr. Heard has been a consultant or received research grants from Cadence Pharmaceuticals, McNeil Consumer Healthcare, and Cumberland Pharmaceuticals.

On 5 p.m. on the day before Thanksgiving, Dr. Alan Caroe, a general practitioner in Las Cruces, N.M., had to decide whether to prescribe an opiate medication to "a very smooth individual from out of town who had a story that was just barely plausible."

Dr. Caroe felt he had insufficient expertise in opioid management, an area that’s complex and difficult and fraught with risk but also an opportunity to help patients in chronic pain, he said in an interview. He needed a quick consultation, but who would answer the phone on that day, at that hour?

Experts at the chronic pain and headache clinic at Project ECHO (Extension for Community Healthcare Outcomes), that’s who. They walked him through the complex issues in the case, which led him to retract an opiate prescription that he initially had phoned into a pharmacy for this patient.

Sherry Boschert/IMNG Medical Media

Real-time consultations are only a part of Project ECHO, an award-winning program based at the University of New Mexico in Albuquerque. In addition, the program provides weekly videoconferences, not only to discuss cases but also to educate and mentor community physicians to take on frontline management of chronic diseases in their geographic areas.

The aim is to act as a multiplier, and to expand the health system’s capacity to manage common, chronic, but complex diseases, Dr. Sanjeev Arora explained in a presentation at the annual meeting of the American Academy of Pain Medicine. New Mexico’s 1.8 million people are spread across 121,000 square miles, and 32 of the state’s 33 counties are listed as medically underserved areas.

Project ECHO began with a focus on improving the care of patients with hepatitis C, and its success has spawned Project ECHO programs for asthma, rheumatology, HIV infection, cardiac risk reduction, chronic pain management, geriatrics, palliative care, substance abuse, prevention of teenage suicide, high-risk pregnancy, childhood obesity, child psychiatry, psychotherapy, antibiotic stewardship, and ethics consultation. More than 400 clinical sites can now connect with Project ECHO.

The Project ECHO model has been cloned by the University of Washington in Seattle, the U.S. Veterans Health Administration, the U.S. Department of Defense, and the country of India, among other entities. The focus is not just on helping rural areas; the University of Chicago’s project works with urban physicians in the community to improve the care of black patients with difficult-to-treat hypertension, whose numbers would overwhelm the limited number of specialists.

When the project’s director, Dr. Arora, a gastroenterologist and hepatologist, founded Project ECHO in 2002, an estimated 28,000 people in the state had hepatitis C, and patients faced an 8-month waiting list to be seen at Dr. Arora’s specialty clinic, which often required traveling long distances. The project has conducted more than 500 "telehealth clinics" on hepatitis C, and has helped get more than 5,000 patients into hepatitis C treatment who previously had no access to care, said Dr. Arora, a professor of medicine at the University of New Mexico.

"We want to transform the nature of what primary care looks like in the United States," he said.

The quality of care these patients are getting in the community rivals the quality at the university, and minorities’ access to care is expanding, a prospective study of 407 patients found. A sustained viral response to treatment for hepatitis C was achieved in 58% of patients managed at the university and by 58% of patients managed by primary care physicians at rural and prison sites who participated in Project ECHO (N. Engl. J. Med. 2011;364:2199-2207). Response rates to different subtypes of hepatitis C also did not differ significantly between the two groups.

Patients who received care at the Project ECHO community sites, however, were significantly more likely to be racial/ethnic minorities (68%), compared with the university’s patients (49%), he said. The cure rate at community sites was significantly higher than cure rates reported in previous community-based studies of hepatitis C treatment, which hovered around 20%, he added. This may be a result of Project ECHO’s emphasis on best-practices protocols and other attributes.

"Project ECHO has brought so much balance. We’ve reduced variation in prescribing" practices for pain medications, for example, Dr. Joanna G. Katzman said in a separate presentation at the meeting. "The degree to which people have evolved blows my mind."

Dr. Katzman, director of Project ECHO’s chronic pain and headache clinic and a neurologist at the University of New Mexico, said that her weekly videoconference typically starts at noon so that primary care physicians can join in during their lunch break. Participants get free CME credits.

The project’s interdisciplinary team of experts and remote participants spend the first half-hour reviewing and discussing three or four cases that have been faxed in by remote participants, followed by 25-30 minutes of didactic presentations. A second hour covers more cases, for those who can stay on. Once a month, the videoconference includes a skills demonstration, such as a trigger point examination or a procedure. Community physicians who miss the live videoconference can watch a video of it later.

"It’s the best use of lunchtime that you can consider," said Dr. Caroe, the generalist in Las Cruces.

Since starting in 2009, Project ECHO’s chronic pain and headache clinic sessions have attracted 474 participants in 168 locations in multiple states, averaging more than six sessions per attendee. In all, 42% are physicians, 23% are nurses or physician assistants, and 35% are others including pharmacists and chiropractors.

Physician assistant Debra Newman worked for several years as a community health extension agent at a rural clinic in Espanola, N.M., with part of her salary paid by the clinic and part by Project ECHO. She managed hundreds of patients who were referred to her for everything from simple low back pain to fibromyalgia, rheumatoid arthritis, and failed back surgery syndrome.

"After sitting in on Project ECHO for years, I could manage many of these patients on my own," said Ms. Newman, now of Christus St. Vincent Regional Medical Center in Santa Fe, N.M. As a P.A., she could practice independently if a supervising physician was within 100 miles – but, she said, she still took complex cases to the teleconference for consultations.

Project ECHO is funded by grants from state and federal government sources and the Robert Wood Johnson Foundation. Large health care systems are cloning the model because they see that it’s a cost-effective way to provide specialty services to more patients without transferring them to specialty care, Dr. Arora said.

"It isn’t expensive if you think that you’re training someone out there to replace you," Dr. Rollin M. Gallagher said in a separate presentation at the meeting. Project ECHO inspired the creation of the similarly-modeled Veterans Affairs SCAN (Specialty Care Access Network), said Dr. Gallagher, deputy national program director for pain management in the Veterans Health Administration and director for pain policy and primary care research at Penn Pain Medicine at the University of Pennsylvania, Philadelphia.

Dr. Ilene R. Robeck runs what she calls a "poor man’s Project ECHO" that provides pain management education, mentoring, and consultations primarily to physicians at three Veterans Affairs medical centers in Florida. "As much as I thought [Project ECHO] was a fantastic program, the resources needed were really higher than the resources I had," she said in an interview.

Funded by a federal grant through September 2013, her project offers a weekly telephone audioconference and immediate access to expert consultations by phone – initiatives that stress the education of participants as much as individual case consultations.

"The results have been overwhelmingly positive," with close to 100 health care providers now calling in from VA facilities around the country each week, said Dr. Robeck of Bay Pines (Fla.) Veterans Affairs Healthcare System.

When Dr. Caroe first heard about Project ECHO, he listened to the weekly conferences by phone because the Internet connection for videoconferencing was too slow where he was practicing in Chaparral, N.M. He now videoconferences each week on a faster connection at his current practice in Las Cruces.

The nearest pain specialists are in Albuquerque (about 260 miles away and too far for many patients to travel for routine visits) or in El Paso, Tex. Crossing state lines for care can create problems with insurance.

He has no doubt that the skills he has gained through Project ECHO have benefited his patients. One 49-year-old female engineer had suffered nearly a lifetime of terrible migraine headaches. Prior to Project ECHO’s didactic and clinical presentations, Dr. Caroe had never heard of premenstrual migraine, and the patient had never noticed that her headaches regularly got worse 2 days before the start of her menstrual period.

"She went from monthly hell" to treatment with a low-dose, short-term estrogen patch to get her through her 4-day period of risk, he said. When she came in for a follow-up visit recently, she told him, "You changed my life."

Dr. Arora has received research funding from Genentech, Gilead, Pharmasset, Tibotec, Vertex, and ZymoGenetics. The other people interviewed for this story reported having no financial disclosures.

On 5 p.m. on the day before Thanksgiving, Dr. Alan Caroe, a general practitioner in Las Cruces, N.M., had to decide whether to prescribe an opiate medication to "a very smooth individual from out of town who had a story that was just barely plausible."

Dr. Caroe felt he had insufficient expertise in opioid management, an area that’s complex and difficult and fraught with risk but also an opportunity to help patients in chronic pain, he said in an interview. He needed a quick consultation, but who would answer the phone on that day, at that hour?

Experts at the chronic pain and headache clinic at Project ECHO (Extension for Community Healthcare Outcomes), that’s who. They walked him through the complex issues in the case, which led him to retract an opiate prescription that he initially had phoned into a pharmacy for this patient.

Sherry Boschert/IMNG Medical Media

Real-time consultations are only a part of Project ECHO, an award-winning program based at the University of New Mexico in Albuquerque. In addition, the program provides weekly videoconferences, not only to discuss cases but also to educate and mentor community physicians to take on frontline management of chronic diseases in their geographic areas.

The aim is to act as a multiplier, and to expand the health system’s capacity to manage common, chronic, but complex diseases, Dr. Sanjeev Arora explained in a presentation at the annual meeting of the American Academy of Pain Medicine. New Mexico’s 1.8 million people are spread across 121,000 square miles, and 32 of the state’s 33 counties are listed as medically underserved areas.

Project ECHO began with a focus on improving the care of patients with hepatitis C, and its success has spawned Project ECHO programs for asthma, rheumatology, HIV infection, cardiac risk reduction, chronic pain management, geriatrics, palliative care, substance abuse, prevention of teenage suicide, high-risk pregnancy, childhood obesity, child psychiatry, psychotherapy, antibiotic stewardship, and ethics consultation. More than 400 clinical sites can now connect with Project ECHO.

The Project ECHO model has been cloned by the University of Washington in Seattle, the U.S. Veterans Health Administration, the U.S. Department of Defense, and the country of India, among other entities. The focus is not just on helping rural areas; the University of Chicago’s project works with urban physicians in the community to improve the care of black patients with difficult-to-treat hypertension, whose numbers would overwhelm the limited number of specialists.

When the project’s director, Dr. Arora, a gastroenterologist and hepatologist, founded Project ECHO in 2002, an estimated 28,000 people in the state had hepatitis C, and patients faced an 8-month waiting list to be seen at Dr. Arora’s specialty clinic, which often required traveling long distances. The project has conducted more than 500 "telehealth clinics" on hepatitis C, and has helped get more than 5,000 patients into hepatitis C treatment who previously had no access to care, said Dr. Arora, a professor of medicine at the University of New Mexico.

"We want to transform the nature of what primary care looks like in the United States," he said.

The quality of care these patients are getting in the community rivals the quality at the university, and minorities’ access to care is expanding, a prospective study of 407 patients found. A sustained viral response to treatment for hepatitis C was achieved in 58% of patients managed at the university and by 58% of patients managed by primary care physicians at rural and prison sites who participated in Project ECHO (N. Engl. J. Med. 2011;364:2199-2207). Response rates to different subtypes of hepatitis C also did not differ significantly between the two groups.

Patients who received care at the Project ECHO community sites, however, were significantly more likely to be racial/ethnic minorities (68%), compared with the university’s patients (49%), he said. The cure rate at community sites was significantly higher than cure rates reported in previous community-based studies of hepatitis C treatment, which hovered around 20%, he added. This may be a result of Project ECHO’s emphasis on best-practices protocols and other attributes.

"Project ECHO has brought so much balance. We’ve reduced variation in prescribing" practices for pain medications, for example, Dr. Joanna G. Katzman said in a separate presentation at the meeting. "The degree to which people have evolved blows my mind."

Dr. Katzman, director of Project ECHO’s chronic pain and headache clinic and a neurologist at the University of New Mexico, said that her weekly videoconference typically starts at noon so that primary care physicians can join in during their lunch break. Participants get free CME credits.

The project’s interdisciplinary team of experts and remote participants spend the first half-hour reviewing and discussing three or four cases that have been faxed in by remote participants, followed by 25-30 minutes of didactic presentations. A second hour covers more cases, for those who can stay on. Once a month, the videoconference includes a skills demonstration, such as a trigger point examination or a procedure. Community physicians who miss the live videoconference can watch a video of it later.

"It’s the best use of lunchtime that you can consider," said Dr. Caroe, the generalist in Las Cruces.

Since starting in 2009, Project ECHO’s chronic pain and headache clinic sessions have attracted 474 participants in 168 locations in multiple states, averaging more than six sessions per attendee. In all, 42% are physicians, 23% are nurses or physician assistants, and 35% are others including pharmacists and chiropractors.

Physician assistant Debra Newman worked for several years as a community health extension agent at a rural clinic in Espanola, N.M., with part of her salary paid by the clinic and part by Project ECHO. She managed hundreds of patients who were referred to her for everything from simple low back pain to fibromyalgia, rheumatoid arthritis, and failed back surgery syndrome.

"After sitting in on Project ECHO for years, I could manage many of these patients on my own," said Ms. Newman, now of Christus St. Vincent Regional Medical Center in Santa Fe, N.M. As a P.A., she could practice independently if a supervising physician was within 100 miles – but, she said, she still took complex cases to the teleconference for consultations.

Project ECHO is funded by grants from state and federal government sources and the Robert Wood Johnson Foundation. Large health care systems are cloning the model because they see that it’s a cost-effective way to provide specialty services to more patients without transferring them to specialty care, Dr. Arora said.

"It isn’t expensive if you think that you’re training someone out there to replace you," Dr. Rollin M. Gallagher said in a separate presentation at the meeting. Project ECHO inspired the creation of the similarly-modeled Veterans Affairs SCAN (Specialty Care Access Network), said Dr. Gallagher, deputy national program director for pain management in the Veterans Health Administration and director for pain policy and primary care research at Penn Pain Medicine at the University of Pennsylvania, Philadelphia.

Dr. Ilene R. Robeck runs what she calls a "poor man’s Project ECHO" that provides pain management education, mentoring, and consultations primarily to physicians at three Veterans Affairs medical centers in Florida. "As much as I thought [Project ECHO] was a fantastic program, the resources needed were really higher than the resources I had," she said in an interview.

Funded by a federal grant through September 2013, her project offers a weekly telephone audioconference and immediate access to expert consultations by phone – initiatives that stress the education of participants as much as individual case consultations.

"The results have been overwhelmingly positive," with close to 100 health care providers now calling in from VA facilities around the country each week, said Dr. Robeck of Bay Pines (Fla.) Veterans Affairs Healthcare System.

When Dr. Caroe first heard about Project ECHO, he listened to the weekly conferences by phone because the Internet connection for videoconferencing was too slow where he was practicing in Chaparral, N.M. He now videoconferences each week on a faster connection at his current practice in Las Cruces.

The nearest pain specialists are in Albuquerque (about 260 miles away and too far for many patients to travel for routine visits) or in El Paso, Tex. Crossing state lines for care can create problems with insurance.

He has no doubt that the skills he has gained through Project ECHO have benefited his patients. One 49-year-old female engineer had suffered nearly a lifetime of terrible migraine headaches. Prior to Project ECHO’s didactic and clinical presentations, Dr. Caroe had never heard of premenstrual migraine, and the patient had never noticed that her headaches regularly got worse 2 days before the start of her menstrual period.

"She went from monthly hell" to treatment with a low-dose, short-term estrogen patch to get her through her 4-day period of risk, he said. When she came in for a follow-up visit recently, she told him, "You changed my life."

Dr. Arora has received research funding from Genentech, Gilead, Pharmasset, Tibotec, Vertex, and ZymoGenetics. The other people interviewed for this story reported having no financial disclosures.

On 5 p.m. on the day before Thanksgiving, Dr. Alan Caroe, a general practitioner in Las Cruces, N.M., had to decide whether to prescribe an opiate medication to "a very smooth individual from out of town who had a story that was just barely plausible."

Dr. Caroe felt he had insufficient expertise in opioid management, an area that’s complex and difficult and fraught with risk but also an opportunity to help patients in chronic pain, he said in an interview. He needed a quick consultation, but who would answer the phone on that day, at that hour?

Experts at the chronic pain and headache clinic at Project ECHO (Extension for Community Healthcare Outcomes), that’s who. They walked him through the complex issues in the case, which led him to retract an opiate prescription that he initially had phoned into a pharmacy for this patient.

Sherry Boschert/IMNG Medical Media

Real-time consultations are only a part of Project ECHO, an award-winning program based at the University of New Mexico in Albuquerque. In addition, the program provides weekly videoconferences, not only to discuss cases but also to educate and mentor community physicians to take on frontline management of chronic diseases in their geographic areas.

The aim is to act as a multiplier, and to expand the health system’s capacity to manage common, chronic, but complex diseases, Dr. Sanjeev Arora explained in a presentation at the annual meeting of the American Academy of Pain Medicine. New Mexico’s 1.8 million people are spread across 121,000 square miles, and 32 of the state’s 33 counties are listed as medically underserved areas.

Project ECHO began with a focus on improving the care of patients with hepatitis C, and its success has spawned Project ECHO programs for asthma, rheumatology, HIV infection, cardiac risk reduction, chronic pain management, geriatrics, palliative care, substance abuse, prevention of teenage suicide, high-risk pregnancy, childhood obesity, child psychiatry, psychotherapy, antibiotic stewardship, and ethics consultation. More than 400 clinical sites can now connect with Project ECHO.

The Project ECHO model has been cloned by the University of Washington in Seattle, the U.S. Veterans Health Administration, the U.S. Department of Defense, and the country of India, among other entities. The focus is not just on helping rural areas; the University of Chicago’s project works with urban physicians in the community to improve the care of black patients with difficult-to-treat hypertension, whose numbers would overwhelm the limited number of specialists.

When the project’s director, Dr. Arora, a gastroenterologist and hepatologist, founded Project ECHO in 2002, an estimated 28,000 people in the state had hepatitis C, and patients faced an 8-month waiting list to be seen at Dr. Arora’s specialty clinic, which often required traveling long distances. The project has conducted more than 500 "telehealth clinics" on hepatitis C, and has helped get more than 5,000 patients into hepatitis C treatment who previously had no access to care, said Dr. Arora, a professor of medicine at the University of New Mexico.

"We want to transform the nature of what primary care looks like in the United States," he said.

The quality of care these patients are getting in the community rivals the quality at the university, and minorities’ access to care is expanding, a prospective study of 407 patients found. A sustained viral response to treatment for hepatitis C was achieved in 58% of patients managed at the university and by 58% of patients managed by primary care physicians at rural and prison sites who participated in Project ECHO (N. Engl. J. Med. 2011;364:2199-2207). Response rates to different subtypes of hepatitis C also did not differ significantly between the two groups.

Patients who received care at the Project ECHO community sites, however, were significantly more likely to be racial/ethnic minorities (68%), compared with the university’s patients (49%), he said. The cure rate at community sites was significantly higher than cure rates reported in previous community-based studies of hepatitis C treatment, which hovered around 20%, he added. This may be a result of Project ECHO’s emphasis on best-practices protocols and other attributes.

"Project ECHO has brought so much balance. We’ve reduced variation in prescribing" practices for pain medications, for example, Dr. Joanna G. Katzman said in a separate presentation at the meeting. "The degree to which people have evolved blows my mind."

Dr. Katzman, director of Project ECHO’s chronic pain and headache clinic and a neurologist at the University of New Mexico, said that her weekly videoconference typically starts at noon so that primary care physicians can join in during their lunch break. Participants get free CME credits.

The project’s interdisciplinary team of experts and remote participants spend the first half-hour reviewing and discussing three or four cases that have been faxed in by remote participants, followed by 25-30 minutes of didactic presentations. A second hour covers more cases, for those who can stay on. Once a month, the videoconference includes a skills demonstration, such as a trigger point examination or a procedure. Community physicians who miss the live videoconference can watch a video of it later.

"It’s the best use of lunchtime that you can consider," said Dr. Caroe, the generalist in Las Cruces.

Since starting in 2009, Project ECHO’s chronic pain and headache clinic sessions have attracted 474 participants in 168 locations in multiple states, averaging more than six sessions per attendee. In all, 42% are physicians, 23% are nurses or physician assistants, and 35% are others including pharmacists and chiropractors.

Physician assistant Debra Newman worked for several years as a community health extension agent at a rural clinic in Espanola, N.M., with part of her salary paid by the clinic and part by Project ECHO. She managed hundreds of patients who were referred to her for everything from simple low back pain to fibromyalgia, rheumatoid arthritis, and failed back surgery syndrome.

"After sitting in on Project ECHO for years, I could manage many of these patients on my own," said Ms. Newman, now of Christus St. Vincent Regional Medical Center in Santa Fe, N.M. As a P.A., she could practice independently if a supervising physician was within 100 miles – but, she said, she still took complex cases to the teleconference for consultations.

Project ECHO is funded by grants from state and federal government sources and the Robert Wood Johnson Foundation. Large health care systems are cloning the model because they see that it’s a cost-effective way to provide specialty services to more patients without transferring them to specialty care, Dr. Arora said.

"It isn’t expensive if you think that you’re training someone out there to replace you," Dr. Rollin M. Gallagher said in a separate presentation at the meeting. Project ECHO inspired the creation of the similarly-modeled Veterans Affairs SCAN (Specialty Care Access Network), said Dr. Gallagher, deputy national program director for pain management in the Veterans Health Administration and director for pain policy and primary care research at Penn Pain Medicine at the University of Pennsylvania, Philadelphia.

Dr. Ilene R. Robeck runs what she calls a "poor man’s Project ECHO" that provides pain management education, mentoring, and consultations primarily to physicians at three Veterans Affairs medical centers in Florida. "As much as I thought [Project ECHO] was a fantastic program, the resources needed were really higher than the resources I had," she said in an interview.

Funded by a federal grant through September 2013, her project offers a weekly telephone audioconference and immediate access to expert consultations by phone – initiatives that stress the education of participants as much as individual case consultations.

"The results have been overwhelmingly positive," with close to 100 health care providers now calling in from VA facilities around the country each week, said Dr. Robeck of Bay Pines (Fla.) Veterans Affairs Healthcare System.

When Dr. Caroe first heard about Project ECHO, he listened to the weekly conferences by phone because the Internet connection for videoconferencing was too slow where he was practicing in Chaparral, N.M. He now videoconferences each week on a faster connection at his current practice in Las Cruces.

The nearest pain specialists are in Albuquerque (about 260 miles away and too far for many patients to travel for routine visits) or in El Paso, Tex. Crossing state lines for care can create problems with insurance.

He has no doubt that the skills he has gained through Project ECHO have benefited his patients. One 49-year-old female engineer had suffered nearly a lifetime of terrible migraine headaches. Prior to Project ECHO’s didactic and clinical presentations, Dr. Caroe had never heard of premenstrual migraine, and the patient had never noticed that her headaches regularly got worse 2 days before the start of her menstrual period.

"She went from monthly hell" to treatment with a low-dose, short-term estrogen patch to get her through her 4-day period of risk, he said. When she came in for a follow-up visit recently, she told him, "You changed my life."

Dr. Arora has received research funding from Genentech, Gilead, Pharmasset, Tibotec, Vertex, and ZymoGenetics. The other people interviewed for this story reported having no financial disclosures.

PALM SPRINGS, CALIF. – The degree of sacroiliac joint pain relief provided by intra-articular steroid injection of the sacroiliac joint did not predict the duration of pain relief from subsequent radiofrequency ablation of the lateral branches that innervate the sacroiliac joint, judging from findings from a retrospective study of 80 patients.

Based on these results, patients who get only 25%-49% relief of pain from steroid injection of the sacroiliac joint (SISI) should not be disqualified from undergoing radiofrequency ablation of the lateral branches, Dr. Jianguo Cheng and his associates suggested in an award-winning poster and plenary presentation at the annual meeting of the American Academy of Pain Medicine.

The study retrospectively collected data on 87 patients undergoing radiofrequency ablation of the lateral branches who’d had a preoperative SISI between January 2006 and June 2009 at The Cleveland Clinic. The seven patients who were missing follow-up data were excluded from the final analysis.

In all, 60 of the 80 patients in the analysis reported at least 50% pain relief as a result of SISI (75%) and 20 patients reported less than 50% pain relief (25%). After radiofrequency ablation of the lateral branches, approximately 50% of all patients reported at least a 50% reduction in pain. The degree of pain relief from radiofrequency ablation did not differ significantly at follow-up visits 1, 3, 6, and 12 months between patients who had experienced 25%-49% pain relief after SISI and patients who reported 50% or greater pain relief after SISI, said Dr. Cheng, who is professor of anesthesiology and program director of pain medicine fellowship program of Cleveland Clinic Foundation.

The analysis adjusted for the effects of potential confounders. Patients who had experienced less than 50% pain relief after SISI were significantly younger than those with at least 50% pain relief after SISI (a mean of 52 years vs. 59 years) and significantly less likely to have had gradual onset of their chronic back pain (60% vs. 82%) and more likely to have had pain with extension or axial rotation (80% vs. 52%). Other characteristics did not differ between groups.

Although the efficacy of radiofrequency ablation of the lateral branches at 3 months was comparable to reports in the literature, the efficacy after 6 months was lower in the study compared with previous reports. Approximately 40% of patients in the study had at least a 50% reduction in pain 6 months after radiofrequency ablation compared with 52%-57% in published reports, Dr. Cheng said. This difference may be due to the older age of patients in the current study compared with previous ones (58 vs. 52 years on average), a higher rate of previous spine surgery (30% vs. 21%), and greater likelihood of multiple pain complaints and opioid use in the current cohort (70% vs. 46%), he suggested.

The current study is larger than most previous ones but is limited by its retrospective design, Dr. Cheng said.

In general, 16%-30% of cases of chronic lower back pain can be attributed to sacroiliac joint pain. Radiofrequency ablation of the lateral branches has emerged as a promising modality in recent years while other treatment modalities have provided mixed and often disappointing results, including pharmacotherapy, viscosupplementation, prolotherapy, chiropractic manipulation, intra-articular injections, and surgical fixation, he said. The findings of the current study should help inform pain interventionists in deciding who is a candidate for radiofrequency ablation.

Dr. Cheng reported having no financial disclosures.

PALM SPRINGS, CALIF. – The degree of sacroiliac joint pain relief provided by intra-articular steroid injection of the sacroiliac joint did not predict the duration of pain relief from subsequent radiofrequency ablation of the lateral branches that innervate the sacroiliac joint, judging from findings from a retrospective study of 80 patients.

Based on these results, patients who get only 25%-49% relief of pain from steroid injection of the sacroiliac joint (SISI) should not be disqualified from undergoing radiofrequency ablation of the lateral branches, Dr. Jianguo Cheng and his associates suggested in an award-winning poster and plenary presentation at the annual meeting of the American Academy of Pain Medicine.

The study retrospectively collected data on 87 patients undergoing radiofrequency ablation of the lateral branches who’d had a preoperative SISI between January 2006 and June 2009 at The Cleveland Clinic. The seven patients who were missing follow-up data were excluded from the final analysis.

In all, 60 of the 80 patients in the analysis reported at least 50% pain relief as a result of SISI (75%) and 20 patients reported less than 50% pain relief (25%). After radiofrequency ablation of the lateral branches, approximately 50% of all patients reported at least a 50% reduction in pain. The degree of pain relief from radiofrequency ablation did not differ significantly at follow-up visits 1, 3, 6, and 12 months between patients who had experienced 25%-49% pain relief after SISI and patients who reported 50% or greater pain relief after SISI, said Dr. Cheng, who is professor of anesthesiology and program director of pain medicine fellowship program of Cleveland Clinic Foundation.

The analysis adjusted for the effects of potential confounders. Patients who had experienced less than 50% pain relief after SISI were significantly younger than those with at least 50% pain relief after SISI (a mean of 52 years vs. 59 years) and significantly less likely to have had gradual onset of their chronic back pain (60% vs. 82%) and more likely to have had pain with extension or axial rotation (80% vs. 52%). Other characteristics did not differ between groups.

Although the efficacy of radiofrequency ablation of the lateral branches at 3 months was comparable to reports in the literature, the efficacy after 6 months was lower in the study compared with previous reports. Approximately 40% of patients in the study had at least a 50% reduction in pain 6 months after radiofrequency ablation compared with 52%-57% in published reports, Dr. Cheng said. This difference may be due to the older age of patients in the current study compared with previous ones (58 vs. 52 years on average), a higher rate of previous spine surgery (30% vs. 21%), and greater likelihood of multiple pain complaints and opioid use in the current cohort (70% vs. 46%), he suggested.

The current study is larger than most previous ones but is limited by its retrospective design, Dr. Cheng said.

In general, 16%-30% of cases of chronic lower back pain can be attributed to sacroiliac joint pain. Radiofrequency ablation of the lateral branches has emerged as a promising modality in recent years while other treatment modalities have provided mixed and often disappointing results, including pharmacotherapy, viscosupplementation, prolotherapy, chiropractic manipulation, intra-articular injections, and surgical fixation, he said. The findings of the current study should help inform pain interventionists in deciding who is a candidate for radiofrequency ablation.

Dr. Cheng reported having no financial disclosures.

PALM SPRINGS, CALIF. – The degree of sacroiliac joint pain relief provided by intra-articular steroid injection of the sacroiliac joint did not predict the duration of pain relief from subsequent radiofrequency ablation of the lateral branches that innervate the sacroiliac joint, judging from findings from a retrospective study of 80 patients.

Based on these results, patients who get only 25%-49% relief of pain from steroid injection of the sacroiliac joint (SISI) should not be disqualified from undergoing radiofrequency ablation of the lateral branches, Dr. Jianguo Cheng and his associates suggested in an award-winning poster and plenary presentation at the annual meeting of the American Academy of Pain Medicine.

The study retrospectively collected data on 87 patients undergoing radiofrequency ablation of the lateral branches who’d had a preoperative SISI between January 2006 and June 2009 at The Cleveland Clinic. The seven patients who were missing follow-up data were excluded from the final analysis.

In all, 60 of the 80 patients in the analysis reported at least 50% pain relief as a result of SISI (75%) and 20 patients reported less than 50% pain relief (25%). After radiofrequency ablation of the lateral branches, approximately 50% of all patients reported at least a 50% reduction in pain. The degree of pain relief from radiofrequency ablation did not differ significantly at follow-up visits 1, 3, 6, and 12 months between patients who had experienced 25%-49% pain relief after SISI and patients who reported 50% or greater pain relief after SISI, said Dr. Cheng, who is professor of anesthesiology and program director of pain medicine fellowship program of Cleveland Clinic Foundation.

The analysis adjusted for the effects of potential confounders. Patients who had experienced less than 50% pain relief after SISI were significantly younger than those with at least 50% pain relief after SISI (a mean of 52 years vs. 59 years) and significantly less likely to have had gradual onset of their chronic back pain (60% vs. 82%) and more likely to have had pain with extension or axial rotation (80% vs. 52%). Other characteristics did not differ between groups.

Although the efficacy of radiofrequency ablation of the lateral branches at 3 months was comparable to reports in the literature, the efficacy after 6 months was lower in the study compared with previous reports. Approximately 40% of patients in the study had at least a 50% reduction in pain 6 months after radiofrequency ablation compared with 52%-57% in published reports, Dr. Cheng said. This difference may be due to the older age of patients in the current study compared with previous ones (58 vs. 52 years on average), a higher rate of previous spine surgery (30% vs. 21%), and greater likelihood of multiple pain complaints and opioid use in the current cohort (70% vs. 46%), he suggested.

The current study is larger than most previous ones but is limited by its retrospective design, Dr. Cheng said.

In general, 16%-30% of cases of chronic lower back pain can be attributed to sacroiliac joint pain. Radiofrequency ablation of the lateral branches has emerged as a promising modality in recent years while other treatment modalities have provided mixed and often disappointing results, including pharmacotherapy, viscosupplementation, prolotherapy, chiropractic manipulation, intra-articular injections, and surgical fixation, he said. The findings of the current study should help inform pain interventionists in deciding who is a candidate for radiofrequency ablation.

Dr. Cheng reported having no financial disclosures.

SAN DIEGO – Hospitalists arrived in hope and in unabashed need of hearing about balancing work and home lives.

One said he was looking for tips on balancing the competing demands of work and home. "It’s never balanced," lamented another, a female hospitalist with a full-time physician husband and three children.

Someone else said he wanted to find ways to prevent burnout. "I’m already burned out," said another at the annual meeting of the Society of Hospital Medicine.

An office-based physician in private practice said he was wondering if hospital medicine might offer a "better," more balanced way to practice. "I just quit my job" due to burnout, one hospitalist admitted.

Sherry Boschert/IMNG Medical Media

Work-life balance boils down to one’s relationships not only with others but with one’s self, said session moderator Dr. Carole Warde. She encouraged everyone to translate some of the same core competencies expected of hospitalists professionally to manage these relationships, including "be engaged," "listen actively," "work in teams," and "resolve conflicts."

"Relationships never come easy. They always come from a place of work," said Dr. Warde, who recently joined the Greater Los Angeles Veterans Affairs Health System to practice as a primary care physician and to set up the VA’s version of patient-centered medical homes.

She adapted a passage from the book by Parker J. Palmer, "The Courage to Teach: Exploring the Inner Landscape of a Teacher’s Life" (10th anniversary edition, Wiley, 2007) as it might apply to physicians: "As I practice, I project the condition of my soul onto my patients, colleagues, family, and friends and our way of being together. Doctoring holds a mirror to the soul. If I am willing to look at that mirror, I have a chance to gain self-knowledge. Knowing myself is as crucial to good doctoring as knowing my patients and my subject," Dr. Warde said.

"This isn’t something that anybody told me in medical school," she said. Physicians who don’t pay attention to their well-being risk emotionally withdrawing into a self-protective shell, which reduces their ability to understand patients’ needs, impairs clinical decision making, and leads to inattentiveness, loss of meaning, and burnout, she said.

A panel of three hospitalists at the session described their own attempts to balance work and home life.

Dr. Diana Childers, an academic hospitalist at the University of California, San Diego, said that with a husband in the U.S. Navy, two children, and her own diagnosis of type 1 diabetes to manage, "time off seems to disappear." She plans her exercise a week in advance. "If I can exercise three to four times a week, that’s good," she said.

She is supported by her husband, a nanny, a departmental chief who "lets me complain," and colleagues who reciprocate in covering for each other when needed. Dr. Childers encouraged hospitalists to join a volunteer project in the workplace to help them find a colleague that they can connect with and talk to about their work-life challenges.

Dr. Mark Shapiro, in private hospitalist practice in San Diego, said the reciprocal relationships between colleagues in his 12-person group also helped manage the stress of work schedules. The group is considering hiring some mid-level practitioners to share the load.

"One of the variables I realized I have the most control over is how I physically feel at the end of the day. That was something that wasn’t being paid attention to," he said. Dr. Shapiro now consciously reminds himself of basic such as drinking water to stay hydrated, and avoiding hospital food when possible.

Sherry Boschert/IMNG Medical Media

Dr. Lisa Shieh, an academic hospitalist at Stanford (Calif.) University, said that support from her department chair to address frequently-changing work hours made a big difference in stress levels. Hiring a nanny and a gardener lets her spend more time with her husband (also a physician) and children.

Finding a mentor after 5 years as a hospitalist "really helped me," Dr. Shieh said. She regularly schedules lunch with a friend at work so they can unwind together, and taps people outside her group, too. "One of my best friends is a surgeon. Sometimes I just call him and say, ‘What do you think of this?’ " Dr. Shieh said.

Stress, Quantified

The U.S. Physician Work Life Study surveyed 5,704 primary care and subspecialty physicians and found that the key factors increasing or mitigating stress were demands (such as work hours, time pressures, or a heavy case mix), control (over workplace chaos, resources, and personal life), and support from colleagues and significant others (Stress Health 2002;18:37-42).

When demands outweigh control and support, stress levels will be high, Dr. Warde said.

In a recent survey of hospitalists at 20 U.S. academic medical centers, 67% reported high stress, 57% reported having 20% or less protected academic time, 54% were satisfied with their ability to control their schedule, 63% were satisfied with the support from their division chief, and 70%-80% were satisfied with their professional relationships (Arch. Intern. Med. 2011;171:782-785).

Dr. Warde recommended an exercise for evaluating one’s work-life balance: Create a grid with three categories on the horizontal axis – Demand, Control, and Support – and three categories on the vertical axis: Personal, Family, and Professional. Fill in each column of the grid as they apply to you. "You’ll be able to identify simple ways to alter" some of the factors that you list to foster balance and reduce the stress in your life, she said.

"The thing not to do is to ignore it," Dr. Warde said.

The speakers reported having no financial disclosures.

SAN DIEGO – Hospitalists arrived in hope and in unabashed need of hearing about balancing work and home lives.

One said he was looking for tips on balancing the competing demands of work and home. "It’s never balanced," lamented another, a female hospitalist with a full-time physician husband and three children.

Someone else said he wanted to find ways to prevent burnout. "I’m already burned out," said another at the annual meeting of the Society of Hospital Medicine.

An office-based physician in private practice said he was wondering if hospital medicine might offer a "better," more balanced way to practice. "I just quit my job" due to burnout, one hospitalist admitted.

Sherry Boschert/IMNG Medical Media

Work-life balance boils down to one’s relationships not only with others but with one’s self, said session moderator Dr. Carole Warde. She encouraged everyone to translate some of the same core competencies expected of hospitalists professionally to manage these relationships, including "be engaged," "listen actively," "work in teams," and "resolve conflicts."

"Relationships never come easy. They always come from a place of work," said Dr. Warde, who recently joined the Greater Los Angeles Veterans Affairs Health System to practice as a primary care physician and to set up the VA’s version of patient-centered medical homes.

She adapted a passage from the book by Parker J. Palmer, "The Courage to Teach: Exploring the Inner Landscape of a Teacher’s Life" (10th anniversary edition, Wiley, 2007) as it might apply to physicians: "As I practice, I project the condition of my soul onto my patients, colleagues, family, and friends and our way of being together. Doctoring holds a mirror to the soul. If I am willing to look at that mirror, I have a chance to gain self-knowledge. Knowing myself is as crucial to good doctoring as knowing my patients and my subject," Dr. Warde said.

"This isn’t something that anybody told me in medical school," she said. Physicians who don’t pay attention to their well-being risk emotionally withdrawing into a self-protective shell, which reduces their ability to understand patients’ needs, impairs clinical decision making, and leads to inattentiveness, loss of meaning, and burnout, she said.

A panel of three hospitalists at the session described their own attempts to balance work and home life.

Dr. Diana Childers, an academic hospitalist at the University of California, San Diego, said that with a husband in the U.S. Navy, two children, and her own diagnosis of type 1 diabetes to manage, "time off seems to disappear." She plans her exercise a week in advance. "If I can exercise three to four times a week, that’s good," she said.

She is supported by her husband, a nanny, a departmental chief who "lets me complain," and colleagues who reciprocate in covering for each other when needed. Dr. Childers encouraged hospitalists to join a volunteer project in the workplace to help them find a colleague that they can connect with and talk to about their work-life challenges.

Dr. Mark Shapiro, in private hospitalist practice in San Diego, said the reciprocal relationships between colleagues in his 12-person group also helped manage the stress of work schedules. The group is considering hiring some mid-level practitioners to share the load.

"One of the variables I realized I have the most control over is how I physically feel at the end of the day. That was something that wasn’t being paid attention to," he said. Dr. Shapiro now consciously reminds himself of basic such as drinking water to stay hydrated, and avoiding hospital food when possible.

Sherry Boschert/IMNG Medical Media

Dr. Lisa Shieh, an academic hospitalist at Stanford (Calif.) University, said that support from her department chair to address frequently-changing work hours made a big difference in stress levels. Hiring a nanny and a gardener lets her spend more time with her husband (also a physician) and children.

Finding a mentor after 5 years as a hospitalist "really helped me," Dr. Shieh said. She regularly schedules lunch with a friend at work so they can unwind together, and taps people outside her group, too. "One of my best friends is a surgeon. Sometimes I just call him and say, ‘What do you think of this?’ " Dr. Shieh said.

Stress, Quantified

The U.S. Physician Work Life Study surveyed 5,704 primary care and subspecialty physicians and found that the key factors increasing or mitigating stress were demands (such as work hours, time pressures, or a heavy case mix), control (over workplace chaos, resources, and personal life), and support from colleagues and significant others (Stress Health 2002;18:37-42).

When demands outweigh control and support, stress levels will be high, Dr. Warde said.

In a recent survey of hospitalists at 20 U.S. academic medical centers, 67% reported high stress, 57% reported having 20% or less protected academic time, 54% were satisfied with their ability to control their schedule, 63% were satisfied with the support from their division chief, and 70%-80% were satisfied with their professional relationships (Arch. Intern. Med. 2011;171:782-785).

Dr. Warde recommended an exercise for evaluating one’s work-life balance: Create a grid with three categories on the horizontal axis – Demand, Control, and Support – and three categories on the vertical axis: Personal, Family, and Professional. Fill in each column of the grid as they apply to you. "You’ll be able to identify simple ways to alter" some of the factors that you list to foster balance and reduce the stress in your life, she said.

"The thing not to do is to ignore it," Dr. Warde said.

The speakers reported having no financial disclosures.

SAN DIEGO – Hospitalists arrived in hope and in unabashed need of hearing about balancing work and home lives.

One said he was looking for tips on balancing the competing demands of work and home. "It’s never balanced," lamented another, a female hospitalist with a full-time physician husband and three children.

Someone else said he wanted to find ways to prevent burnout. "I’m already burned out," said another at the annual meeting of the Society of Hospital Medicine.

An office-based physician in private practice said he was wondering if hospital medicine might offer a "better," more balanced way to practice. "I just quit my job" due to burnout, one hospitalist admitted.

Sherry Boschert/IMNG Medical Media

Work-life balance boils down to one’s relationships not only with others but with one’s self, said session moderator Dr. Carole Warde. She encouraged everyone to translate some of the same core competencies expected of hospitalists professionally to manage these relationships, including "be engaged," "listen actively," "work in teams," and "resolve conflicts."

"Relationships never come easy. They always come from a place of work," said Dr. Warde, who recently joined the Greater Los Angeles Veterans Affairs Health System to practice as a primary care physician and to set up the VA’s version of patient-centered medical homes.

She adapted a passage from the book by Parker J. Palmer, "The Courage to Teach: Exploring the Inner Landscape of a Teacher’s Life" (10th anniversary edition, Wiley, 2007) as it might apply to physicians: "As I practice, I project the condition of my soul onto my patients, colleagues, family, and friends and our way of being together. Doctoring holds a mirror to the soul. If I am willing to look at that mirror, I have a chance to gain self-knowledge. Knowing myself is as crucial to good doctoring as knowing my patients and my subject," Dr. Warde said.

"This isn’t something that anybody told me in medical school," she said. Physicians who don’t pay attention to their well-being risk emotionally withdrawing into a self-protective shell, which reduces their ability to understand patients’ needs, impairs clinical decision making, and leads to inattentiveness, loss of meaning, and burnout, she said.

A panel of three hospitalists at the session described their own attempts to balance work and home life.

Dr. Diana Childers, an academic hospitalist at the University of California, San Diego, said that with a husband in the U.S. Navy, two children, and her own diagnosis of type 1 diabetes to manage, "time off seems to disappear." She plans her exercise a week in advance. "If I can exercise three to four times a week, that’s good," she said.

She is supported by her husband, a nanny, a departmental chief who "lets me complain," and colleagues who reciprocate in covering for each other when needed. Dr. Childers encouraged hospitalists to join a volunteer project in the workplace to help them find a colleague that they can connect with and talk to about their work-life challenges.

Dr. Mark Shapiro, in private hospitalist practice in San Diego, said the reciprocal relationships between colleagues in his 12-person group also helped manage the stress of work schedules. The group is considering hiring some mid-level practitioners to share the load.

"One of the variables I realized I have the most control over is how I physically feel at the end of the day. That was something that wasn’t being paid attention to," he said. Dr. Shapiro now consciously reminds himself of basic such as drinking water to stay hydrated, and avoiding hospital food when possible.

Sherry Boschert/IMNG Medical Media

Dr. Lisa Shieh, an academic hospitalist at Stanford (Calif.) University, said that support from her department chair to address frequently-changing work hours made a big difference in stress levels. Hiring a nanny and a gardener lets her spend more time with her husband (also a physician) and children.

Finding a mentor after 5 years as a hospitalist "really helped me," Dr. Shieh said. She regularly schedules lunch with a friend at work so they can unwind together, and taps people outside her group, too. "One of my best friends is a surgeon. Sometimes I just call him and say, ‘What do you think of this?’ " Dr. Shieh said.

Stress, Quantified

The U.S. Physician Work Life Study surveyed 5,704 primary care and subspecialty physicians and found that the key factors increasing or mitigating stress were demands (such as work hours, time pressures, or a heavy case mix), control (over workplace chaos, resources, and personal life), and support from colleagues and significant others (Stress Health 2002;18:37-42).

When demands outweigh control and support, stress levels will be high, Dr. Warde said.

In a recent survey of hospitalists at 20 U.S. academic medical centers, 67% reported high stress, 57% reported having 20% or less protected academic time, 54% were satisfied with their ability to control their schedule, 63% were satisfied with the support from their division chief, and 70%-80% were satisfied with their professional relationships (Arch. Intern. Med. 2011;171:782-785).

Dr. Warde recommended an exercise for evaluating one’s work-life balance: Create a grid with three categories on the horizontal axis – Demand, Control, and Support – and three categories on the vertical axis: Personal, Family, and Professional. Fill in each column of the grid as they apply to you. "You’ll be able to identify simple ways to alter" some of the factors that you list to foster balance and reduce the stress in your life, she said.

"The thing not to do is to ignore it," Dr. Warde said.

The speakers reported having no financial disclosures.

SAN DIEGO – A plan to form "affinity groups" got off to a rousing start as participants in a women’s-interest session the enthusiastically signed up for a new listserv.

The affinity groups are designed to promote communication among members with common interests, said Dr. Janet M. Nagamine, a Society of Hospital Medicine board member who led an interest group gathering at the annual meeting. She also pumped participants for other ideas on how SHM can help address the challenges facing female hospitalists, especially the hot topic of persistent pay disparities between male and female hospitalists.

Photos Sherry Boschert/IMNG Medical Media

A 2011 survey by the society and the Medical Group Management Association found that female hospitalists were being paid $4,000-$29,000 less than their male counterparts were, after accounting for factors other than sex. The findings follow a previous study reporting sex-based pay disparities among hospitalists (Inquiry 2004;41:301-15) and more general studies reporting significant sex-based pay disparities among physicians (Health Aff. 2009;28:557-66 and Health Aff. 2011;30:193-201).

Anecdotes shared by women at the interest group meeting made the statistics come to life. One said she left a hospitalist position when she discovered that her two male colleagues were being paid $30,000/year more than she was. Another described complaining to her company’s CEO that male hospitalists were being paid $20,000/year more than she was, only to be brushed off by the executive – another woman – who told her that individual contracts were none of her business.

"It’s disappointing to be having this conversation," Dr. Nagamine said. "I’m appalled in this day and age to hear about things like." The solution has to be systemic, not just on a case-by-case basis, she added.

Dr. Patience E. Reich suggested ways to fight systemic gender bias during an earlier session on "Women in Hospital Medicine." Pay disparities may be the easiest for hospitalist companies to correct, by conducting self-audits assessing compensation within the company and adopting policies that promote transparency around how pay levels are set.

"Treat this as part of your business strategy," and engage male colleagues in initiatives around gender issues, said Dr. Reich, a hospitalist at Wake Forest University, Winston-Salem, N.C.

Another challenge facing women more than men is the need for flexibility in work structures. In families with two working parents, women do twice as much housework and three times as much child care as men, said Dr. Reich’s co-moderator of the session, Dr. Rachel George. The U.S. Bureau of Labor Statistics tells a similar story with its data indicating that married women spend about twice as much time on both endeavors as married men do.

Find a solution that fits your workplace, whether it’s offering part-time positions, job-sharing, child-care services, or something else, Dr. Reich said. "Please involve the top business line people when making these decisions," she added. "They will help construct something that’s workable."

A systemic lack of mentors and sponsors can negatively affect the careers of female hospitalists, who may lack access to informal networks, high-visibility assignments, and transparency around career paths. Women need to reach out to physician colleagues, male and female, inside and outside the specialty, to find mentors and sponsors. Hospitalist leaders should try to connect women with mentors and sponsors, she said.

The solutions also are personal, not just systemic, said Dr. George, regional CEO for Cogent HMG, Brentwood, Tenn., a hospitalist management group.

She urged women to step up and create opportunities. "Be part of a committee in your hospital. Participate. Show up. Speak up. Follow up," so that you and your abilities become better known, Dr. George said.

Ease up on yourself if you take a management position and not everyone likes you – that’s to be expected, she added. Lighten up, and don’t blame gender bias for every problem. Partner up with your spouse to share the load at home and/or find help for you both. Finally, "woman up" to support women’s choices in balancing work and home life, even if they don’t match your own, she said.

She suggested that SHM might compile "best practices" for facilitating a gender balance in hospitalist groups. Others suggested holding a workshop on negotiation skills, educating male colleagues about gender bias, organizing a weekend workshop on women’s issues, or even "mentored implementation of mentoring women for leadership."

"I think there’s going to be some fun work ahead," Dr. Nagamine said.

The speakers reported having no financial disclosures.

* This story was updated on Tuesday, April 10.

SAN DIEGO – A plan to form "affinity groups" got off to a rousing start as participants in a women’s-interest session the enthusiastically signed up for a new listserv.

The affinity groups are designed to promote communication among members with common interests, said Dr. Janet M. Nagamine, a Society of Hospital Medicine board member who led an interest group gathering at the annual meeting. She also pumped participants for other ideas on how SHM can help address the challenges facing female hospitalists, especially the hot topic of persistent pay disparities between male and female hospitalists.

Photos Sherry Boschert/IMNG Medical Media

A 2011 survey by the society and the Medical Group Management Association found that female hospitalists were being paid $4,000-$29,000 less than their male counterparts were, after accounting for factors other than sex. The findings follow a previous study reporting sex-based pay disparities among hospitalists (Inquiry 2004;41:301-15) and more general studies reporting significant sex-based pay disparities among physicians (Health Aff. 2009;28:557-66 and Health Aff. 2011;30:193-201).

Anecdotes shared by women at the interest group meeting made the statistics come to life. One said she left a hospitalist position when she discovered that her two male colleagues were being paid $30,000/year more than she was. Another described complaining to her company’s CEO that male hospitalists were being paid $20,000/year more than she was, only to be brushed off by the executive – another woman – who told her that individual contracts were none of her business.

"It’s disappointing to be having this conversation," Dr. Nagamine said. "I’m appalled in this day and age to hear about things like." The solution has to be systemic, not just on a case-by-case basis, she added.

Dr. Patience E. Reich suggested ways to fight systemic gender bias during an earlier session on "Women in Hospital Medicine." Pay disparities may be the easiest for hospitalist companies to correct, by conducting self-audits assessing compensation within the company and adopting policies that promote transparency around how pay levels are set.

"Treat this as part of your business strategy," and engage male colleagues in initiatives around gender issues, said Dr. Reich, a hospitalist at Wake Forest University, Winston-Salem, N.C.

Another challenge facing women more than men is the need for flexibility in work structures. In families with two working parents, women do twice as much housework and three times as much child care as men, said Dr. Reich’s co-moderator of the session, Dr. Rachel George. The U.S. Bureau of Labor Statistics tells a similar story with its data indicating that married women spend about twice as much time on both endeavors as married men do.

Find a solution that fits your workplace, whether it’s offering part-time positions, job-sharing, child-care services, or something else, Dr. Reich said. "Please involve the top business line people when making these decisions," she added. "They will help construct something that’s workable."

A systemic lack of mentors and sponsors can negatively affect the careers of female hospitalists, who may lack access to informal networks, high-visibility assignments, and transparency around career paths. Women need to reach out to physician colleagues, male and female, inside and outside the specialty, to find mentors and sponsors. Hospitalist leaders should try to connect women with mentors and sponsors, she said.

The solutions also are personal, not just systemic, said Dr. George, regional CEO for Cogent HMG, Brentwood, Tenn., a hospitalist management group.

She urged women to step up and create opportunities. "Be part of a committee in your hospital. Participate. Show up. Speak up. Follow up," so that you and your abilities become better known, Dr. George said.

Ease up on yourself if you take a management position and not everyone likes you – that’s to be expected, she added. Lighten up, and don’t blame gender bias for every problem. Partner up with your spouse to share the load at home and/or find help for you both. Finally, "woman up" to support women’s choices in balancing work and home life, even if they don’t match your own, she said.

She suggested that SHM might compile "best practices" for facilitating a gender balance in hospitalist groups. Others suggested holding a workshop on negotiation skills, educating male colleagues about gender bias, organizing a weekend workshop on women’s issues, or even "mentored implementation of mentoring women for leadership."

"I think there’s going to be some fun work ahead," Dr. Nagamine said.

The speakers reported having no financial disclosures.

* This story was updated on Tuesday, April 10.

SAN DIEGO – A plan to form "affinity groups" got off to a rousing start as participants in a women’s-interest session the enthusiastically signed up for a new listserv.

The affinity groups are designed to promote communication among members with common interests, said Dr. Janet M. Nagamine, a Society of Hospital Medicine board member who led an interest group gathering at the annual meeting. She also pumped participants for other ideas on how SHM can help address the challenges facing female hospitalists, especially the hot topic of persistent pay disparities between male and female hospitalists.

Photos Sherry Boschert/IMNG Medical Media

A 2011 survey by the society and the Medical Group Management Association found that female hospitalists were being paid $4,000-$29,000 less than their male counterparts were, after accounting for factors other than sex. The findings follow a previous study reporting sex-based pay disparities among hospitalists (Inquiry 2004;41:301-15) and more general studies reporting significant sex-based pay disparities among physicians (Health Aff. 2009;28:557-66 and Health Aff. 2011;30:193-201).

Anecdotes shared by women at the interest group meeting made the statistics come to life. One said she left a hospitalist position when she discovered that her two male colleagues were being paid $30,000/year more than she was. Another described complaining to her company’s CEO that male hospitalists were being paid $20,000/year more than she was, only to be brushed off by the executive – another woman – who told her that individual contracts were none of her business.

"It’s disappointing to be having this conversation," Dr. Nagamine said. "I’m appalled in this day and age to hear about things like." The solution has to be systemic, not just on a case-by-case basis, she added.

Dr. Patience E. Reich suggested ways to fight systemic gender bias during an earlier session on "Women in Hospital Medicine." Pay disparities may be the easiest for hospitalist companies to correct, by conducting self-audits assessing compensation within the company and adopting policies that promote transparency around how pay levels are set.

"Treat this as part of your business strategy," and engage male colleagues in initiatives around gender issues, said Dr. Reich, a hospitalist at Wake Forest University, Winston-Salem, N.C.

Another challenge facing women more than men is the need for flexibility in work structures. In families with two working parents, women do twice as much housework and three times as much child care as men, said Dr. Reich’s co-moderator of the session, Dr. Rachel George. The U.S. Bureau of Labor Statistics tells a similar story with its data indicating that married women spend about twice as much time on both endeavors as married men do.

Find a solution that fits your workplace, whether it’s offering part-time positions, job-sharing, child-care services, or something else, Dr. Reich said. "Please involve the top business line people when making these decisions," she added. "They will help construct something that’s workable."

A systemic lack of mentors and sponsors can negatively affect the careers of female hospitalists, who may lack access to informal networks, high-visibility assignments, and transparency around career paths. Women need to reach out to physician colleagues, male and female, inside and outside the specialty, to find mentors and sponsors. Hospitalist leaders should try to connect women with mentors and sponsors, she said.

The solutions also are personal, not just systemic, said Dr. George, regional CEO for Cogent HMG, Brentwood, Tenn., a hospitalist management group.

She urged women to step up and create opportunities. "Be part of a committee in your hospital. Participate. Show up. Speak up. Follow up," so that you and your abilities become better known, Dr. George said.

Ease up on yourself if you take a management position and not everyone likes you – that’s to be expected, she added. Lighten up, and don’t blame gender bias for every problem. Partner up with your spouse to share the load at home and/or find help for you both. Finally, "woman up" to support women’s choices in balancing work and home life, even if they don’t match your own, she said.

She suggested that SHM might compile "best practices" for facilitating a gender balance in hospitalist groups. Others suggested holding a workshop on negotiation skills, educating male colleagues about gender bias, organizing a weekend workshop on women’s issues, or even "mentored implementation of mentoring women for leadership."

"I think there’s going to be some fun work ahead," Dr. Nagamine said.

The speakers reported having no financial disclosures.

* This story was updated on Tuesday, April 10.

PALM SPRINGS, CALIF. – A single question asked of patients whose pain interferes with their activities may help identify those who also are depressed and rule out those without depression.

Investigators analyzed data on 5,595 participants in the National Epidemiologic Study for Alcohol and Related Conditions (NESARC) who said that pain interfered with their work inside and outside the home "quite a bit" or "extremely" during the past 4 weeks. When asked, "How much of the time during the past 4 weeks have you felt downhearted or depressed?" 33% answered, "None of the time" and 67% responded, "A little," "Some," "Most," or "All of the time."

The answers identified those with comorbid depression with a sensitivity of 84% and a specificity of 43%, Jana M. Mossey, Ph.D. and her associates reported in a poster presentation at the annual meeting of the American Academy of Pain Medicine. The question provided a positive predictive value of 46% and a negative predictive value of 82%, reported Dr. Mossey, professor of epidemiology and biostatistics at Drexel University, Philadelphia.

In other words, a report of recent depressed feelings identified 84% of individuals who had depression currently or within the past 12 months. The strong negative predictive value shows that people who said they hadn’t been downhearted or depressed were highly unlikely to have depression and were unlikely to be underreporting their negative feelings.

The diagnosis of depression was ascertained in the NESARC study by assessing participants using the AUDADIS-IV (Alcohol Use Disorder and Associated Disabilities Interview Schedule IV), a fully structured diagnostic interview to assess mental disorders specified in the DSM-IV. Use of the AUDADIS-IV to identify depressive disorders allowed for an assessment of sensitivity and specificity that rarely is obtained in pain clinics, the investigators noted.

The AUDADIS-IV is as reliable as the Diagnostic Interview Schedule or the World Health Organization Composite International Diagnostic Interview for assessing Axis I disorders, previous studies suggest.

Participants in the NESARC study also were assessed using the 12-item Short Form Health Survey version 2 (SF-12v2), which provided the question about how much they had felt downhearted or depressed in the past 4 weeks (J. Clin. Psychiatry 2005;66:1206-15).

The NESARC study was conducted in a community setting (in individuals’ homes), but Dr. Mossey and her associates restricted their analysis to a sample that was similar to patients seen in pain clinics in terms of the degree to which pain intensity interfered with their activities. Previous studies found that 66% of 15,537 patients in one pain practice and 85% of patients in another pain practice reported that pain interfered with their activities "quite a bit" or "extremely," the investigators noted.

In the current retrospective analysis, the sensitivity, specificity, and negative predictive value of the depression question were similar across subgroups by age, sex, and race. Overall, participants had a mean age of 44 years, 63% were female, 54% were non-Hispanic whites, 24% were black, and 22% were other races.

The sensitivity of the depression question increased as participants’ self-rated health worsened, from a 73% sensitivity in those who reported excellent health to a 94% sensitivity in those who reported poor health. The specificity of the depression question decreased with poorer self-rated health, from a 71% specificity in people reporting excellent health to a specificity of 24% in those reporting poor health.

Although the depression question may provide a quick and easy way to screen for depression in patients with significant activity-limiting pain, its utility is somewhat challenged by a large number of false positives, Dr. Mossey suggested. Among those who reported being downhearted or depressed, 64% had no DSM-IV diagnosis of depressive disorder. More study is needed comparing the true and false positives.

Patients with chronic pain commonly have depression that often goes undetected or undertreated, which can negatively affect patients’ clinical course, coping mechanisms, and chances of recovering from the pain, previous studies have shown.

Dr. Mossey reported having no financial disclosures.

PALM SPRINGS, CALIF. – A single question asked of patients whose pain interferes with their activities may help identify those who also are depressed and rule out those without depression.

Investigators analyzed data on 5,595 participants in the National Epidemiologic Study for Alcohol and Related Conditions (NESARC) who said that pain interfered with their work inside and outside the home "quite a bit" or "extremely" during the past 4 weeks. When asked, "How much of the time during the past 4 weeks have you felt downhearted or depressed?" 33% answered, "None of the time" and 67% responded, "A little," "Some," "Most," or "All of the time."

The answers identified those with comorbid depression with a sensitivity of 84% and a specificity of 43%, Jana M. Mossey, Ph.D. and her associates reported in a poster presentation at the annual meeting of the American Academy of Pain Medicine. The question provided a positive predictive value of 46% and a negative predictive value of 82%, reported Dr. Mossey, professor of epidemiology and biostatistics at Drexel University, Philadelphia.

In other words, a report of recent depressed feelings identified 84% of individuals who had depression currently or within the past 12 months. The strong negative predictive value shows that people who said they hadn’t been downhearted or depressed were highly unlikely to have depression and were unlikely to be underreporting their negative feelings.

The diagnosis of depression was ascertained in the NESARC study by assessing participants using the AUDADIS-IV (Alcohol Use Disorder and Associated Disabilities Interview Schedule IV), a fully structured diagnostic interview to assess mental disorders specified in the DSM-IV. Use of the AUDADIS-IV to identify depressive disorders allowed for an assessment of sensitivity and specificity that rarely is obtained in pain clinics, the investigators noted.

The AUDADIS-IV is as reliable as the Diagnostic Interview Schedule or the World Health Organization Composite International Diagnostic Interview for assessing Axis I disorders, previous studies suggest.

Participants in the NESARC study also were assessed using the 12-item Short Form Health Survey version 2 (SF-12v2), which provided the question about how much they had felt downhearted or depressed in the past 4 weeks (J. Clin. Psychiatry 2005;66:1206-15).

The NESARC study was conducted in a community setting (in individuals’ homes), but Dr. Mossey and her associates restricted their analysis to a sample that was similar to patients seen in pain clinics in terms of the degree to which pain intensity interfered with their activities. Previous studies found that 66% of 15,537 patients in one pain practice and 85% of patients in another pain practice reported that pain interfered with their activities "quite a bit" or "extremely," the investigators noted.

In the current retrospective analysis, the sensitivity, specificity, and negative predictive value of the depression question were similar across subgroups by age, sex, and race. Overall, participants had a mean age of 44 years, 63% were female, 54% were non-Hispanic whites, 24% were black, and 22% were other races.

The sensitivity of the depression question increased as participants’ self-rated health worsened, from a 73% sensitivity in those who reported excellent health to a 94% sensitivity in those who reported poor health. The specificity of the depression question decreased with poorer self-rated health, from a 71% specificity in people reporting excellent health to a specificity of 24% in those reporting poor health.

Although the depression question may provide a quick and easy way to screen for depression in patients with significant activity-limiting pain, its utility is somewhat challenged by a large number of false positives, Dr. Mossey suggested. Among those who reported being downhearted or depressed, 64% had no DSM-IV diagnosis of depressive disorder. More study is needed comparing the true and false positives.

Patients with chronic pain commonly have depression that often goes undetected or undertreated, which can negatively affect patients’ clinical course, coping mechanisms, and chances of recovering from the pain, previous studies have shown.

Dr. Mossey reported having no financial disclosures.

PALM SPRINGS, CALIF. – A single question asked of patients whose pain interferes with their activities may help identify those who also are depressed and rule out those without depression.

Investigators analyzed data on 5,595 participants in the National Epidemiologic Study for Alcohol and Related Conditions (NESARC) who said that pain interfered with their work inside and outside the home "quite a bit" or "extremely" during the past 4 weeks. When asked, "How much of the time during the past 4 weeks have you felt downhearted or depressed?" 33% answered, "None of the time" and 67% responded, "A little," "Some," "Most," or "All of the time."

The answers identified those with comorbid depression with a sensitivity of 84% and a specificity of 43%, Jana M. Mossey, Ph.D. and her associates reported in a poster presentation at the annual meeting of the American Academy of Pain Medicine. The question provided a positive predictive value of 46% and a negative predictive value of 82%, reported Dr. Mossey, professor of epidemiology and biostatistics at Drexel University, Philadelphia.

In other words, a report of recent depressed feelings identified 84% of individuals who had depression currently or within the past 12 months. The strong negative predictive value shows that people who said they hadn’t been downhearted or depressed were highly unlikely to have depression and were unlikely to be underreporting their negative feelings.

The diagnosis of depression was ascertained in the NESARC study by assessing participants using the AUDADIS-IV (Alcohol Use Disorder and Associated Disabilities Interview Schedule IV), a fully structured diagnostic interview to assess mental disorders specified in the DSM-IV. Use of the AUDADIS-IV to identify depressive disorders allowed for an assessment of sensitivity and specificity that rarely is obtained in pain clinics, the investigators noted.

The AUDADIS-IV is as reliable as the Diagnostic Interview Schedule or the World Health Organization Composite International Diagnostic Interview for assessing Axis I disorders, previous studies suggest.

Participants in the NESARC study also were assessed using the 12-item Short Form Health Survey version 2 (SF-12v2), which provided the question about how much they had felt downhearted or depressed in the past 4 weeks (J. Clin. Psychiatry 2005;66:1206-15).

The NESARC study was conducted in a community setting (in individuals’ homes), but Dr. Mossey and her associates restricted their analysis to a sample that was similar to patients seen in pain clinics in terms of the degree to which pain intensity interfered with their activities. Previous studies found that 66% of 15,537 patients in one pain practice and 85% of patients in another pain practice reported that pain interfered with their activities "quite a bit" or "extremely," the investigators noted.

In the current retrospective analysis, the sensitivity, specificity, and negative predictive value of the depression question were similar across subgroups by age, sex, and race. Overall, participants had a mean age of 44 years, 63% were female, 54% were non-Hispanic whites, 24% were black, and 22% were other races.

The sensitivity of the depression question increased as participants’ self-rated health worsened, from a 73% sensitivity in those who reported excellent health to a 94% sensitivity in those who reported poor health. The specificity of the depression question decreased with poorer self-rated health, from a 71% specificity in people reporting excellent health to a specificity of 24% in those reporting poor health.

Although the depression question may provide a quick and easy way to screen for depression in patients with significant activity-limiting pain, its utility is somewhat challenged by a large number of false positives, Dr. Mossey suggested. Among those who reported being downhearted or depressed, 64% had no DSM-IV diagnosis of depressive disorder. More study is needed comparing the true and false positives.

Patients with chronic pain commonly have depression that often goes undetected or undertreated, which can negatively affect patients’ clinical course, coping mechanisms, and chances of recovering from the pain, previous studies have shown.

Dr. Mossey reported having no financial disclosures.