The Hospitalist

For current and future hospitalists, there’s no doubt that knowledge of quality improvement (QI) fundamentals is an important component of a successful practice. One physician team set out to provide their trainees with that QI foundation and described the results.

Wavebreakmedia/Thinkstock

“We believed that implementing a formal step-wise QI curriculum would not only meet the Accreditation Council of Graduate Medical Education (ACGME) requirements, but also increase residents’ knowledge of QI fundamentals and ultimately establish a culture of continuous improvement aiming to provide high-value care to our health care consumers,” said lead author J. Colt Cowdell, MD, MBA, of Mayo Clinic in Jacksonville, Fla.

Prior to any interventions, the team surveyed internal medicine residents regarding three unique patient scenarios and scored their answers. Residents were then assigned to one of five unique QI projects for the academic year in combination with a structured didactic QI curriculum.

After the structured progressive curriculum, in combination with team-based QI projects, residents were surveyed again. Results showed not only increased QI knowledge, but also improved patient safety and reduced waste.

“Keys to successful implementation included a thorough explanation of the need for this curriculum to the learners and ensuring that QI teams were multidisciplinary – residents, QI experts, nurses, techs, pharmacy, administrators, etc.,” said Dr. Cowdell.

For hospitalists in an academic setting, this work can provide a framework to incorporate QI into their residency programs. “I hope, if they have a passion for QI, they would seek out opportunities to mentor residents and help lead multidisciplinary team-based projects,” Dr. Cowdell said.
 

Reference

1. Cowdell, JC; Trautman, C; Lewis, M; Dawson, N. Integration of a Novel Quality Improvement Curriculum into an Internal Medicine Residency Program. Abstract published at Hospital Medicine 2018; April 8-11; Orlando, Fla. Abstract 54. https://www.shmabstracts.com/abstract/integration-of-a-novel-quality-improvement-curriculum-into-an-internal-medicine-residency-program/. Accessed Dec. 11, 2018.

For current and future hospitalists, there’s no doubt that knowledge of quality improvement (QI) fundamentals is an important component of a successful practice. One physician team set out to provide their trainees with that QI foundation and described the results.

Wavebreakmedia/Thinkstock

“We believed that implementing a formal step-wise QI curriculum would not only meet the Accreditation Council of Graduate Medical Education (ACGME) requirements, but also increase residents’ knowledge of QI fundamentals and ultimately establish a culture of continuous improvement aiming to provide high-value care to our health care consumers,” said lead author J. Colt Cowdell, MD, MBA, of Mayo Clinic in Jacksonville, Fla.

Prior to any interventions, the team surveyed internal medicine residents regarding three unique patient scenarios and scored their answers. Residents were then assigned to one of five unique QI projects for the academic year in combination with a structured didactic QI curriculum.

After the structured progressive curriculum, in combination with team-based QI projects, residents were surveyed again. Results showed not only increased QI knowledge, but also improved patient safety and reduced waste.

“Keys to successful implementation included a thorough explanation of the need for this curriculum to the learners and ensuring that QI teams were multidisciplinary – residents, QI experts, nurses, techs, pharmacy, administrators, etc.,” said Dr. Cowdell.

For hospitalists in an academic setting, this work can provide a framework to incorporate QI into their residency programs. “I hope, if they have a passion for QI, they would seek out opportunities to mentor residents and help lead multidisciplinary team-based projects,” Dr. Cowdell said.
 

Reference

1. Cowdell, JC; Trautman, C; Lewis, M; Dawson, N. Integration of a Novel Quality Improvement Curriculum into an Internal Medicine Residency Program. Abstract published at Hospital Medicine 2018; April 8-11; Orlando, Fla. Abstract 54. https://www.shmabstracts.com/abstract/integration-of-a-novel-quality-improvement-curriculum-into-an-internal-medicine-residency-program/. Accessed Dec. 11, 2018.

For current and future hospitalists, there’s no doubt that knowledge of quality improvement (QI) fundamentals is an important component of a successful practice. One physician team set out to provide their trainees with that QI foundation and described the results.

Wavebreakmedia/Thinkstock

“We believed that implementing a formal step-wise QI curriculum would not only meet the Accreditation Council of Graduate Medical Education (ACGME) requirements, but also increase residents’ knowledge of QI fundamentals and ultimately establish a culture of continuous improvement aiming to provide high-value care to our health care consumers,” said lead author J. Colt Cowdell, MD, MBA, of Mayo Clinic in Jacksonville, Fla.

Prior to any interventions, the team surveyed internal medicine residents regarding three unique patient scenarios and scored their answers. Residents were then assigned to one of five unique QI projects for the academic year in combination with a structured didactic QI curriculum.

After the structured progressive curriculum, in combination with team-based QI projects, residents were surveyed again. Results showed not only increased QI knowledge, but also improved patient safety and reduced waste.

“Keys to successful implementation included a thorough explanation of the need for this curriculum to the learners and ensuring that QI teams were multidisciplinary – residents, QI experts, nurses, techs, pharmacy, administrators, etc.,” said Dr. Cowdell.

For hospitalists in an academic setting, this work can provide a framework to incorporate QI into their residency programs. “I hope, if they have a passion for QI, they would seek out opportunities to mentor residents and help lead multidisciplinary team-based projects,” Dr. Cowdell said.
 

Reference

1. Cowdell, JC; Trautman, C; Lewis, M; Dawson, N. Integration of a Novel Quality Improvement Curriculum into an Internal Medicine Residency Program. Abstract published at Hospital Medicine 2018; April 8-11; Orlando, Fla. Abstract 54. https://www.shmabstracts.com/abstract/integration-of-a-novel-quality-improvement-curriculum-into-an-internal-medicine-residency-program/. Accessed Dec. 11, 2018.

I first heard the term “discharge before noon” (DCBN) as a third-year medical student starting my internal medicine rotation. The basic idea made sense: Get patients out of the hospital early so rooms can be cleaned more quickly and new patients wouldn’t have to wait so long in the ED.

It quickly became apparent, however, that a lot of moving parts had to align perfectly for DCBN. Even if we prioritized rounding on dischargeable patients (starting 8-9 a.m. depending on the service/day), they still needed prescriptions filled, normal clothes to wear, and a way to get home, which wasn’t easy to coordinate while we were still trying to see all the other patients.

Fast forward through 5 years of residency/fellowship experience and DCBN seems even more unrealistic in hospitalized pediatric patients. As a simple example, discharge criteria for dehydration (one of the most common reasons for pediatric hospitalization) include demonstrating the ability to drink enough liquids to stay hydrated. Who’s going to force children to stay up all night sipping fluids (plus changing all those diapers or taking them to the bathroom)? If the child stays on intravenous fluids overnight, we have to monitor at least through breakfast, likely lunch, thus making DCBN nearly impossible.

In a January 2019 article in the Journal of Hospital Medicine, Hailey James, MHA, (@Haileyjms on Twitter) and her colleagues demonstrated an association between DCBN and decreased length of stay (LOS) for medical but not surgical pediatric discharges.¹ This made them question if DCBN is an appropriate metric for discharge efficiency, as well as workflow differences between services. Many hospitals, however, still try to push DCBN as a goal (see Destino et al in the same January 2019 issue of JHM²), which could potentially lead to people trying to game the system.

How does your institution try to make discharge processes more efficient? Is it actually possible to do everything more quickly without sacrificing quality or trainee education? Whether your patients are kids, adults, or both, there are likely many issues in common where we could all learn from each other.

We discussed this topic in #JHMChat on April 15 on Twitter. New to Twitter or not familiar with #JHMChat? Since October 2015, JHM has reviewed and discussed dozens of articles spanning a wide variety of topics related to caring for hospitalized patients. All are welcome to join, including medical students, residents, nurses, practicing hospitalists, and more. It’s a great opportunity to virtually meet and learn from others while earning free CME.

To participate in future chats, type #JHMChat in the search box on the top right corner of your Twitter homepage, click on the “Latest” tab at the top left to see the most recent tweets, and join the conversation (don’t forget the hashtag)!
 

Dr. Chen is a pediatric hospital medicine fellow at Rady Children’s Hospital, University of California, San Diego. She is one of the cofounders/moderators of #PHMFellowJC, serves as a fellow district representative for the American Academy of Pediatrics, and is an active #tweetiatrician at @DrJenChen4kids. This article appeared originally in SHM's official blog The Hospital Leader. Read more recent posts here.

References

1. James HJ et al. The Association of Discharge Before Noon and Length of Stay in Hospitalized Pediatric Patients. J Hosp Med. 2019;14(1):28-32. doi: 10.12788/jhm.3111.

2. Destino L et al. Improving Patient Flow: Analysis of an Initiative to Improve Early Discharge. J Hosp Med. 2019;14(1):22-7. doi: 10.12788/jhm.3133.

I first heard the term “discharge before noon” (DCBN) as a third-year medical student starting my internal medicine rotation. The basic idea made sense: Get patients out of the hospital early so rooms can be cleaned more quickly and new patients wouldn’t have to wait so long in the ED.

It quickly became apparent, however, that a lot of moving parts had to align perfectly for DCBN. Even if we prioritized rounding on dischargeable patients (starting 8-9 a.m. depending on the service/day), they still needed prescriptions filled, normal clothes to wear, and a way to get home, which wasn’t easy to coordinate while we were still trying to see all the other patients.

Fast forward through 5 years of residency/fellowship experience and DCBN seems even more unrealistic in hospitalized pediatric patients. As a simple example, discharge criteria for dehydration (one of the most common reasons for pediatric hospitalization) include demonstrating the ability to drink enough liquids to stay hydrated. Who’s going to force children to stay up all night sipping fluids (plus changing all those diapers or taking them to the bathroom)? If the child stays on intravenous fluids overnight, we have to monitor at least through breakfast, likely lunch, thus making DCBN nearly impossible.

In a January 2019 article in the Journal of Hospital Medicine, Hailey James, MHA, (@Haileyjms on Twitter) and her colleagues demonstrated an association between DCBN and decreased length of stay (LOS) for medical but not surgical pediatric discharges.¹ This made them question if DCBN is an appropriate metric for discharge efficiency, as well as workflow differences between services. Many hospitals, however, still try to push DCBN as a goal (see Destino et al in the same January 2019 issue of JHM²), which could potentially lead to people trying to game the system.

How does your institution try to make discharge processes more efficient? Is it actually possible to do everything more quickly without sacrificing quality or trainee education? Whether your patients are kids, adults, or both, there are likely many issues in common where we could all learn from each other.

We discussed this topic in #JHMChat on April 15 on Twitter. New to Twitter or not familiar with #JHMChat? Since October 2015, JHM has reviewed and discussed dozens of articles spanning a wide variety of topics related to caring for hospitalized patients. All are welcome to join, including medical students, residents, nurses, practicing hospitalists, and more. It’s a great opportunity to virtually meet and learn from others while earning free CME.

To participate in future chats, type #JHMChat in the search box on the top right corner of your Twitter homepage, click on the “Latest” tab at the top left to see the most recent tweets, and join the conversation (don’t forget the hashtag)!
 

Dr. Chen is a pediatric hospital medicine fellow at Rady Children’s Hospital, University of California, San Diego. She is one of the cofounders/moderators of #PHMFellowJC, serves as a fellow district representative for the American Academy of Pediatrics, and is an active #tweetiatrician at @DrJenChen4kids. This article appeared originally in SHM's official blog The Hospital Leader. Read more recent posts here.

References

1. James HJ et al. The Association of Discharge Before Noon and Length of Stay in Hospitalized Pediatric Patients. J Hosp Med. 2019;14(1):28-32. doi: 10.12788/jhm.3111.

2. Destino L et al. Improving Patient Flow: Analysis of an Initiative to Improve Early Discharge. J Hosp Med. 2019;14(1):22-7. doi: 10.12788/jhm.3133.

I first heard the term “discharge before noon” (DCBN) as a third-year medical student starting my internal medicine rotation. The basic idea made sense: Get patients out of the hospital early so rooms can be cleaned more quickly and new patients wouldn’t have to wait so long in the ED.

It quickly became apparent, however, that a lot of moving parts had to align perfectly for DCBN. Even if we prioritized rounding on dischargeable patients (starting 8-9 a.m. depending on the service/day), they still needed prescriptions filled, normal clothes to wear, and a way to get home, which wasn’t easy to coordinate while we were still trying to see all the other patients.

Fast forward through 5 years of residency/fellowship experience and DCBN seems even more unrealistic in hospitalized pediatric patients. As a simple example, discharge criteria for dehydration (one of the most common reasons for pediatric hospitalization) include demonstrating the ability to drink enough liquids to stay hydrated. Who’s going to force children to stay up all night sipping fluids (plus changing all those diapers or taking them to the bathroom)? If the child stays on intravenous fluids overnight, we have to monitor at least through breakfast, likely lunch, thus making DCBN nearly impossible.

In a January 2019 article in the Journal of Hospital Medicine, Hailey James, MHA, (@Haileyjms on Twitter) and her colleagues demonstrated an association between DCBN and decreased length of stay (LOS) for medical but not surgical pediatric discharges.¹ This made them question if DCBN is an appropriate metric for discharge efficiency, as well as workflow differences between services. Many hospitals, however, still try to push DCBN as a goal (see Destino et al in the same January 2019 issue of JHM²), which could potentially lead to people trying to game the system.

How does your institution try to make discharge processes more efficient? Is it actually possible to do everything more quickly without sacrificing quality or trainee education? Whether your patients are kids, adults, or both, there are likely many issues in common where we could all learn from each other.

We discussed this topic in #JHMChat on April 15 on Twitter. New to Twitter or not familiar with #JHMChat? Since October 2015, JHM has reviewed and discussed dozens of articles spanning a wide variety of topics related to caring for hospitalized patients. All are welcome to join, including medical students, residents, nurses, practicing hospitalists, and more. It’s a great opportunity to virtually meet and learn from others while earning free CME.

To participate in future chats, type #JHMChat in the search box on the top right corner of your Twitter homepage, click on the “Latest” tab at the top left to see the most recent tweets, and join the conversation (don’t forget the hashtag)!
 

Dr. Chen is a pediatric hospital medicine fellow at Rady Children’s Hospital, University of California, San Diego. She is one of the cofounders/moderators of #PHMFellowJC, serves as a fellow district representative for the American Academy of Pediatrics, and is an active #tweetiatrician at @DrJenChen4kids. This article appeared originally in SHM's official blog The Hospital Leader. Read more recent posts here.

References

1. James HJ et al. The Association of Discharge Before Noon and Length of Stay in Hospitalized Pediatric Patients. J Hosp Med. 2019;14(1):28-32. doi: 10.12788/jhm.3111.

2. Destino L et al. Improving Patient Flow: Analysis of an Initiative to Improve Early Discharge. J Hosp Med. 2019;14(1):22-7. doi: 10.12788/jhm.3133.

Fewer opioid retail prescriptions are being filled, according to a new report issued by the American Medical Association Opioid Task Force.

AndreyPopov/Getty Images

Opioid prescribing declined by 33% over a 5-year period based on the total number of opioid retail prescriptions filled. Total prescriptions declined from 251.8 million in 2013 to 168.8 million in 2018, according to the report.

The numbers come as the most recent data from the Centers for Disease Control and Prevention show a leveling of deaths involving prescription opioids. The CDC data were most recently updated in January 2019 and cover the period 1999-2017.

A closer look shows that deaths involving prescription opioids, but not other synthetic narcotics, peaked in 2011 and have generally declined since then. Deaths involving other synthetic narcotics, however, have been rising, offsetting the reduction and keeping the total number of deaths involving opioids relatively stable between 2016 and 2017.

Other data released by the AMA Opioid Task Force show that physicians are increasing their use of state-level prescription drug monitoring programs (PDMPs).

In 2017, there were 1.5 million physicians registered to use state PDMPs. That number rose to 1.97 million in 2019. And the physicians are using PDMPs. In 2018, physicians made 460 million PDMP queries, up 56% from 2017 and up 651% from 2014.

More education about opioid prescribing is being sought, with 700,000 physicians completing CME training and accessing other training related to opioid prescribing, pain management, screening for substance use disorders, and other related topics.

While the report does show positive trends, the task force is calling for more action, including more access to naloxone and better access to mental health treatment.

The report notes that more than 66,000 physicians and other health professionals have a federal waiver to prescribe buprenorphine, up more than 28,000 since 2016.

A number of policy recommendations are made in the report, including removing inappropriate administrative burdens or barriers that delay access to medications used in medication-assisted treatment (MAT); removing barriers to comprehensive pain care and rehabilitation programs, and reforming the civil and criminal justice system to help ensure access to high-quality, evidence-based care for opioid use disorder.

“We are at a crossroads in our nation’s efforts to end the opioid epidemic,” AMA Opioid Task Force Chair Patrice A. Harris, MD, stated in the report. “It is time to end delays and barriers to medication-assisted treatment – evidence based care proven to save lives; time for payers, [pharmacy benefit managers] and pharmacy chains to reevaluate and revise policies that restrict opioid therapy to patients based on arbitrary thresholds; and time to commit to helping all patients access evidence-based care for pain and substance use disorders.”

Dr. Harris continued: “Physicians must continue to demonstrate leadership, but unless these actions occur, the progress we are making will not stop patients from dying.”

[email protected]

Fewer opioid retail prescriptions are being filled, according to a new report issued by the American Medical Association Opioid Task Force.

AndreyPopov/Getty Images

Opioid prescribing declined by 33% over a 5-year period based on the total number of opioid retail prescriptions filled. Total prescriptions declined from 251.8 million in 2013 to 168.8 million in 2018, according to the report.

The numbers come as the most recent data from the Centers for Disease Control and Prevention show a leveling of deaths involving prescription opioids. The CDC data were most recently updated in January 2019 and cover the period 1999-2017.

A closer look shows that deaths involving prescription opioids, but not other synthetic narcotics, peaked in 2011 and have generally declined since then. Deaths involving other synthetic narcotics, however, have been rising, offsetting the reduction and keeping the total number of deaths involving opioids relatively stable between 2016 and 2017.

Other data released by the AMA Opioid Task Force show that physicians are increasing their use of state-level prescription drug monitoring programs (PDMPs).

In 2017, there were 1.5 million physicians registered to use state PDMPs. That number rose to 1.97 million in 2019. And the physicians are using PDMPs. In 2018, physicians made 460 million PDMP queries, up 56% from 2017 and up 651% from 2014.

More education about opioid prescribing is being sought, with 700,000 physicians completing CME training and accessing other training related to opioid prescribing, pain management, screening for substance use disorders, and other related topics.

While the report does show positive trends, the task force is calling for more action, including more access to naloxone and better access to mental health treatment.

The report notes that more than 66,000 physicians and other health professionals have a federal waiver to prescribe buprenorphine, up more than 28,000 since 2016.

A number of policy recommendations are made in the report, including removing inappropriate administrative burdens or barriers that delay access to medications used in medication-assisted treatment (MAT); removing barriers to comprehensive pain care and rehabilitation programs, and reforming the civil and criminal justice system to help ensure access to high-quality, evidence-based care for opioid use disorder.

“We are at a crossroads in our nation’s efforts to end the opioid epidemic,” AMA Opioid Task Force Chair Patrice A. Harris, MD, stated in the report. “It is time to end delays and barriers to medication-assisted treatment – evidence based care proven to save lives; time for payers, [pharmacy benefit managers] and pharmacy chains to reevaluate and revise policies that restrict opioid therapy to patients based on arbitrary thresholds; and time to commit to helping all patients access evidence-based care for pain and substance use disorders.”

Dr. Harris continued: “Physicians must continue to demonstrate leadership, but unless these actions occur, the progress we are making will not stop patients from dying.”

[email protected]

Fewer opioid retail prescriptions are being filled, according to a new report issued by the American Medical Association Opioid Task Force.

AndreyPopov/Getty Images

Opioid prescribing declined by 33% over a 5-year period based on the total number of opioid retail prescriptions filled. Total prescriptions declined from 251.8 million in 2013 to 168.8 million in 2018, according to the report.

The numbers come as the most recent data from the Centers for Disease Control and Prevention show a leveling of deaths involving prescription opioids. The CDC data were most recently updated in January 2019 and cover the period 1999-2017.

A closer look shows that deaths involving prescription opioids, but not other synthetic narcotics, peaked in 2011 and have generally declined since then. Deaths involving other synthetic narcotics, however, have been rising, offsetting the reduction and keeping the total number of deaths involving opioids relatively stable between 2016 and 2017.

Other data released by the AMA Opioid Task Force show that physicians are increasing their use of state-level prescription drug monitoring programs (PDMPs).

In 2017, there were 1.5 million physicians registered to use state PDMPs. That number rose to 1.97 million in 2019. And the physicians are using PDMPs. In 2018, physicians made 460 million PDMP queries, up 56% from 2017 and up 651% from 2014.

More education about opioid prescribing is being sought, with 700,000 physicians completing CME training and accessing other training related to opioid prescribing, pain management, screening for substance use disorders, and other related topics.

While the report does show positive trends, the task force is calling for more action, including more access to naloxone and better access to mental health treatment.

The report notes that more than 66,000 physicians and other health professionals have a federal waiver to prescribe buprenorphine, up more than 28,000 since 2016.

A number of policy recommendations are made in the report, including removing inappropriate administrative burdens or barriers that delay access to medications used in medication-assisted treatment (MAT); removing barriers to comprehensive pain care and rehabilitation programs, and reforming the civil and criminal justice system to help ensure access to high-quality, evidence-based care for opioid use disorder.

“We are at a crossroads in our nation’s efforts to end the opioid epidemic,” AMA Opioid Task Force Chair Patrice A. Harris, MD, stated in the report. “It is time to end delays and barriers to medication-assisted treatment – evidence based care proven to save lives; time for payers, [pharmacy benefit managers] and pharmacy chains to reevaluate and revise policies that restrict opioid therapy to patients based on arbitrary thresholds; and time to commit to helping all patients access evidence-based care for pain and substance use disorders.”

Dr. Harris continued: “Physicians must continue to demonstrate leadership, but unless these actions occur, the progress we are making will not stop patients from dying.”

[email protected]

When it comes to anaphylaxis episodes leading to pediatric intensive care–unit stays, peanuts are the most common culprit. Now the results of a recent clinical trial may lead to approval of the first oral medication to ameliorate reactions in children with severe peanut allergies.

copyright mates/Fotolia.com

After 6 months of treatment and 6 months of maintenance therapy, two-thirds of the 372 children who received this treatment could ingest the equivalent of two peanuts without allergic symptoms. Just 4% of the 124 children given a placebo powder were able to consume that amount of peanut without reacting. The treatment was not effective for the small number of adults in the study.

This trial of the drug, called AR101 and developed by Aimmune Therapeutics, was published in Nov. 2018 in the New England Journal of Medicine. The company has submitted a biologics license application to the U.S. Food and Drug Administration, and because the drug has been designated a breakthrough therapy, it will go through an accelerated approval process. It could be on the market by the end of 2019.
 

Reference

1. Rabin RC. New Peanut Allergy Drug Shows ‘Lifesaving’ Potential. New York Times. Nov. 18, 2018. https://www.nytimes.com/2018/11/18/well/live/new-peanut-allergy-drug-shows-lifesaving-potential.html. Accessed Nov. 26, 2018.

When it comes to anaphylaxis episodes leading to pediatric intensive care–unit stays, peanuts are the most common culprit. Now the results of a recent clinical trial may lead to approval of the first oral medication to ameliorate reactions in children with severe peanut allergies.

copyright mates/Fotolia.com

After 6 months of treatment and 6 months of maintenance therapy, two-thirds of the 372 children who received this treatment could ingest the equivalent of two peanuts without allergic symptoms. Just 4% of the 124 children given a placebo powder were able to consume that amount of peanut without reacting. The treatment was not effective for the small number of adults in the study.

This trial of the drug, called AR101 and developed by Aimmune Therapeutics, was published in Nov. 2018 in the New England Journal of Medicine. The company has submitted a biologics license application to the U.S. Food and Drug Administration, and because the drug has been designated a breakthrough therapy, it will go through an accelerated approval process. It could be on the market by the end of 2019.
 

Reference

1. Rabin RC. New Peanut Allergy Drug Shows ‘Lifesaving’ Potential. New York Times. Nov. 18, 2018. https://www.nytimes.com/2018/11/18/well/live/new-peanut-allergy-drug-shows-lifesaving-potential.html. Accessed Nov. 26, 2018.

When it comes to anaphylaxis episodes leading to pediatric intensive care–unit stays, peanuts are the most common culprit. Now the results of a recent clinical trial may lead to approval of the first oral medication to ameliorate reactions in children with severe peanut allergies.

copyright mates/Fotolia.com

After 6 months of treatment and 6 months of maintenance therapy, two-thirds of the 372 children who received this treatment could ingest the equivalent of two peanuts without allergic symptoms. Just 4% of the 124 children given a placebo powder were able to consume that amount of peanut without reacting. The treatment was not effective for the small number of adults in the study.

This trial of the drug, called AR101 and developed by Aimmune Therapeutics, was published in Nov. 2018 in the New England Journal of Medicine. The company has submitted a biologics license application to the U.S. Food and Drug Administration, and because the drug has been designated a breakthrough therapy, it will go through an accelerated approval process. It could be on the market by the end of 2019.
 

Reference

1. Rabin RC. New Peanut Allergy Drug Shows ‘Lifesaving’ Potential. New York Times. Nov. 18, 2018. https://www.nytimes.com/2018/11/18/well/live/new-peanut-allergy-drug-shows-lifesaving-potential.html. Accessed Nov. 26, 2018.

As an academic nurse practitioner hospitalist with faculty and leadership roles, I found that HM19 had many important and helpful topics that apply directly to my practice.

The “Onboarding Best Practices” session provided specific examples and tips for clinical ramp up, enculturation, and orienting staff to an academic career. As a result of this talk, I began the process of establishing a formal enculturation activity for new hires that includes a panel of senior advanced practice provider (APP) hospitalists to give career path advice.

The “Adaptive Leadership for Hospitalists” workshop provided the opportunity to practice emotional intelligence and effective communication in managing routine and difficult leadership interactions. The “Practice Models/Models of Care for Optimal Integration of NPs and PAs” presentation provided insight into variable team structures at other institutions that could be considered for improved efficiency in my group. The “Academic NP/PA” session provided ideas for how to apply for faculty positions in academic institutions. It also gave APPs who have faculty appointment specific illustrations of using current educational, quality improvement, and research projects to promote. I particularly found the “What Mentorship Has Meant to Me” talk significant. It gave practical essential advice on making sure there is chemistry and trust when seeking a mentor and staying engaged to be a successful mentee.

APPs, whether practicing in academic, private, or community settings, should attend the SHM Annual Conference. SHM is very inclusive and proud of APPs as colleagues and leaders. There are topics that directly apply to the needs of APP hospitalists – including career advancement – and that create excitement for APP practice in hospital medicine.

The Annual Conference also provides the very unique opportunity to meet and establish relationships with APP and physician colleagues and leaders nationwide. These relationships lend to career advancing opportunities for collaboration in clinical excellence, education, quality improvement, research, and leadership.
 

Dr. Apodaca is assistant professor and nurse practitioner hospitalist at the University of New Mexico. She is one of the first APPNP/PAs to receive faculty appointment at UNM. She serves as codirector of the UNM APP Hospital Medicine Fellowship and director of the APP Hospital Medicine Team. She is also the president of the New Mexico Chapter of SHM and is the first APP at her institution to achieve designation as a Fellow in Hospital Medicine.

As an academic nurse practitioner hospitalist with faculty and leadership roles, I found that HM19 had many important and helpful topics that apply directly to my practice.

The “Onboarding Best Practices” session provided specific examples and tips for clinical ramp up, enculturation, and orienting staff to an academic career. As a result of this talk, I began the process of establishing a formal enculturation activity for new hires that includes a panel of senior advanced practice provider (APP) hospitalists to give career path advice.

The “Adaptive Leadership for Hospitalists” workshop provided the opportunity to practice emotional intelligence and effective communication in managing routine and difficult leadership interactions. The “Practice Models/Models of Care for Optimal Integration of NPs and PAs” presentation provided insight into variable team structures at other institutions that could be considered for improved efficiency in my group. The “Academic NP/PA” session provided ideas for how to apply for faculty positions in academic institutions. It also gave APPs who have faculty appointment specific illustrations of using current educational, quality improvement, and research projects to promote. I particularly found the “What Mentorship Has Meant to Me” talk significant. It gave practical essential advice on making sure there is chemistry and trust when seeking a mentor and staying engaged to be a successful mentee.

APPs, whether practicing in academic, private, or community settings, should attend the SHM Annual Conference. SHM is very inclusive and proud of APPs as colleagues and leaders. There are topics that directly apply to the needs of APP hospitalists – including career advancement – and that create excitement for APP practice in hospital medicine.

The Annual Conference also provides the very unique opportunity to meet and establish relationships with APP and physician colleagues and leaders nationwide. These relationships lend to career advancing opportunities for collaboration in clinical excellence, education, quality improvement, research, and leadership.
 

Dr. Apodaca is assistant professor and nurse practitioner hospitalist at the University of New Mexico. She is one of the first APPNP/PAs to receive faculty appointment at UNM. She serves as codirector of the UNM APP Hospital Medicine Fellowship and director of the APP Hospital Medicine Team. She is also the president of the New Mexico Chapter of SHM and is the first APP at her institution to achieve designation as a Fellow in Hospital Medicine.

As an academic nurse practitioner hospitalist with faculty and leadership roles, I found that HM19 had many important and helpful topics that apply directly to my practice.

The “Onboarding Best Practices” session provided specific examples and tips for clinical ramp up, enculturation, and orienting staff to an academic career. As a result of this talk, I began the process of establishing a formal enculturation activity for new hires that includes a panel of senior advanced practice provider (APP) hospitalists to give career path advice.

The “Adaptive Leadership for Hospitalists” workshop provided the opportunity to practice emotional intelligence and effective communication in managing routine and difficult leadership interactions. The “Practice Models/Models of Care for Optimal Integration of NPs and PAs” presentation provided insight into variable team structures at other institutions that could be considered for improved efficiency in my group. The “Academic NP/PA” session provided ideas for how to apply for faculty positions in academic institutions. It also gave APPs who have faculty appointment specific illustrations of using current educational, quality improvement, and research projects to promote. I particularly found the “What Mentorship Has Meant to Me” talk significant. It gave practical essential advice on making sure there is chemistry and trust when seeking a mentor and staying engaged to be a successful mentee.

APPs, whether practicing in academic, private, or community settings, should attend the SHM Annual Conference. SHM is very inclusive and proud of APPs as colleagues and leaders. There are topics that directly apply to the needs of APP hospitalists – including career advancement – and that create excitement for APP practice in hospital medicine.

The Annual Conference also provides the very unique opportunity to meet and establish relationships with APP and physician colleagues and leaders nationwide. These relationships lend to career advancing opportunities for collaboration in clinical excellence, education, quality improvement, research, and leadership.
 

Dr. Apodaca is assistant professor and nurse practitioner hospitalist at the University of New Mexico. She is one of the first APPNP/PAs to receive faculty appointment at UNM. She serves as codirector of the UNM APP Hospital Medicine Fellowship and director of the APP Hospital Medicine Team. She is also the president of the New Mexico Chapter of SHM and is the first APP at her institution to achieve designation as a Fellow in Hospital Medicine.

For Matthew Tuck, MD, MEd, FACP, associate section chief for hospital medicine at the Veterans Affairs Medical Center (VAMC) in Washington, leadership is something that hospitalists can and should be learning at every opportunity.

Some of the best insights about effective leadership, teamwork, and process improvement come from the business world and have been slower to infiltrate into hospital settings and hospitalist groups, he says. But Dr. Tuck has tried to take advantage of numerous opportunities for leadership development in his own career.

He has been a hospitalist since 2010 and is part of a group of 13 physicians, all of whom carry clinical, teaching, and research responsibilities while pursuing a variety of education, quality improvement, and performance improvement topics.

“My chair has been generous about giving me time to do teaching and research and to pursue opportunities for career development,” he said. The Washington VAMC works with four affiliate medical schools in the area, and its six daily hospital medicine services are all 100% teaching services with assigned residents and interns.

Dr. Tuck divides his professional time roughly one-third each between clinical – seeing patients 5 months a year on a consultative or inpatient basis with resident teams; administrative in a variety of roles; and research. He has academic appointments at the George Washington University (GWU) School of Medicine and at the Uniformed Services University of Health Sciences in Bethesda, Md. He developed the coursework for teaching evidence-based medicine to first- and second-year medical students at GWU.

He is also part of a large research consortium with five sites and $7.5 million in funding over 5 years from NIH’s National Institute on Minority Health and Health Disparities to study how genetic information from African American patients can predict their response to cardiovascular medications. He serves as the study’s site Principal Investigator at the VAMC.

Opportunities to advance his leadership skills have included the VA’s Aspiring Leaders Program and Leadership Development Mentoring Program, which teach leadership skills on topical subjects such as teaching, communications skills, and finance. The Master Teacher Leadership Development Program for medical faculty at GWU, where he attended medical school and did his internship and residency, offers six intensive, classroom-based 8-week courses over a 1-year period. They cover various topical subjects with faculty from the business world teaching principles of leadership. The program includes a mentoring action plan for participants and leads to a graduate certificate in leadership development from GWU’s Graduate School of Education and Human Development at the end of the year’s studies.

Dr. Tuck credits completing this kind of coursework for his current position of leadership in the VA and he tries to share what he has learned with the medical students he teaches.

“When I was starting out as a physician, I never received training in how to lead a team. I found myself trying to get everything done for my patients while teaching my learners, and I really struggled for the first couple of years to manage these competing demands on my time,” he said.

Now, on the first day of a new clinical rotation, he meets one-on-one with his residents to set out goals and expectations. “I say: ‘This is how I want rounds to be run. What are your expectations?’ That way we make sure we’re collaborating as a team. I don’t know that medical school prepares you for this kind of teamwork. Unless you bring a background in business, you can really struggle.”
 

Interest in hospital medicine

“Throughout our medical training we do a variety of rotations and clerkships. I found myself falling in love with all of them – surgery, psychiatry, obstetrics, and gynecology,” Dr. Tuck explained, as he reflected on how he ended up in hospital medicine. “As someone who was interested in all of these different fields of medicine, I considered myself a true medical generalist. And in hospitalized patients, who struggle with all of the different issues that bring them to the hospital, I saw a compilation of all my experiences in residency training combined in one setting.”

Hospital medicine was a relatively young field at that time, with few academic hospitalists, he said. “But I had good mentors who encouraged me to pursue my educational, research, and administrative interests. My affinity for the VA was also largely due to my training. We worked in multiple settings – academic, community-based, National Institutes of Health, and at the VA.”

Dr. Tuck said that, of all the settings in which he practiced, he felt the VA truly trained him best to be a doctor. “The experience made me feel like a holistic practitioner,” he said. “The system allowed me to take the best care of my patients, since I didn’t have to worry about whether I could make needed referrals to specialists. Very early in my internship year we were seeing very sick patients with multiple comorbidities, but it was easy to get a social worker or case manager involved, compared to other settings, which can be more difficult to navigate.”

While the VA is a “great health system,” Dr. Tuck said, the challenge is learning how to work with its bureaucracy. “If you don’t know how the system works, it can seem to get in your way.” But overall, he said, the VA functions well and compares favorably with private sector hospitals and health systems. That was also the conclusion of a recent study in the Journal of General Internal Medicine, which compared the quality of outpatient and inpatient care in VA and non-VA settings using recent performance measure data.¹ The authors concluded that the VA system performed similarly or better than non-VA health care on most nationally recognized measures of inpatient and outpatient care quality, although there is wide variation between VA facilities.
 

Working with the team

Another major interest for Dr. Tuck is team-based learning, which also grew out of his GWU leadership certificate course work on teaching teams and team development. He is working on a draft paper for publication with coauthor Patrick Rendon, MD, associate program director for the University of New Mexico’s internal medicine residency program, building on the group development stage theory – “Forming/Storming/Norming/Performing” – developed by Tuckman and Jenson.²

The theory offers 12 tips for optimizing inpatient ward team performance, such as getting the learners to buy in at an early stage of a project. “Everyone I talk to about our research is eager to learn how to apply these principles. I don’t think we’re unique at this center. We’re constantly rotating learners through the program. If you apply these principles, you can get learners to be more efficient starting from the first day,” he said.

The current inpatient team model at the Washington VAMC involves a broadly representative team from nursing, case management, social work, the business office, medical coding, utilization management, and administration that convenes every morning to discuss patient navigation and difficult discharges. “Everyone sits around a big table, and the six hospital medicine teams rotate through every fifteen minutes to review their patients’ admitting diagnoses, barriers to discharge and plans of care.”

At the patient’s bedside, a Focused Interdisciplinary Team (FIT) model, which Dr. Tuck helped to implement, incorporates a four-step process with clearly defined roles for the attending, nurse, pharmacist, and case manager or social worker. “Since implementation, our data show overall reductions in lengths of stay,” he said.

Dr. Tuck urges other hospitalists to pursue opportunities available to them to develop their leadership skills. “Look to your professional societies such as the Society of General Internal Medicine (SGIM) or SHM.” For example, SGIM’s Academic Hospitalist Commission, which he cochairs, provides a voice on the national stage for academic hospitalists and cosponsors with SHM an annual Academic Hospitalist Academy to support career development for junior academic hospitalists as educational leaders. Since 2016, its Distinguished Professor of Hospital Medicine recognizes a professor of hospital medicine to give a plenary address at the SGIM national meeting.

SGIM’s SCHOLAR Project, a subgroup of its Academic Hospitalist Commission, has worked to identify features of successful academic hospitalist programs, with the results published in the Journal of Hospital Medicine.³

“We learned that what sets successful programs apart is their leadership – as well as protected time for scholarly pursuits,” he said. “We’re all leaders in this field, whether we view ourselves that way or not.”

References

1. Price RA et al. Comparing quality of care in Veterans Affairs and Non–Veterans Affairs settings. J Gen Intern Med. 2018 Oct;33(10):1631-38.

2. Tuckman B, Jensen M. Stages of small group development revisited. Group and Organizational Studies. 1977;2:419-427.

3. Seymann GB et al. Features of successful academic hospitalist programs: Insights from the SCHOLAR (Successful hospitalists in academics and research) project. J Hosp Med. 2016 Oct;11(10):708-13.

For Matthew Tuck, MD, MEd, FACP, associate section chief for hospital medicine at the Veterans Affairs Medical Center (VAMC) in Washington, leadership is something that hospitalists can and should be learning at every opportunity.

Some of the best insights about effective leadership, teamwork, and process improvement come from the business world and have been slower to infiltrate into hospital settings and hospitalist groups, he says. But Dr. Tuck has tried to take advantage of numerous opportunities for leadership development in his own career.

He has been a hospitalist since 2010 and is part of a group of 13 physicians, all of whom carry clinical, teaching, and research responsibilities while pursuing a variety of education, quality improvement, and performance improvement topics.

“My chair has been generous about giving me time to do teaching and research and to pursue opportunities for career development,” he said. The Washington VAMC works with four affiliate medical schools in the area, and its six daily hospital medicine services are all 100% teaching services with assigned residents and interns.

Dr. Tuck divides his professional time roughly one-third each between clinical – seeing patients 5 months a year on a consultative or inpatient basis with resident teams; administrative in a variety of roles; and research. He has academic appointments at the George Washington University (GWU) School of Medicine and at the Uniformed Services University of Health Sciences in Bethesda, Md. He developed the coursework for teaching evidence-based medicine to first- and second-year medical students at GWU.

He is also part of a large research consortium with five sites and $7.5 million in funding over 5 years from NIH’s National Institute on Minority Health and Health Disparities to study how genetic information from African American patients can predict their response to cardiovascular medications. He serves as the study’s site Principal Investigator at the VAMC.

Opportunities to advance his leadership skills have included the VA’s Aspiring Leaders Program and Leadership Development Mentoring Program, which teach leadership skills on topical subjects such as teaching, communications skills, and finance. The Master Teacher Leadership Development Program for medical faculty at GWU, where he attended medical school and did his internship and residency, offers six intensive, classroom-based 8-week courses over a 1-year period. They cover various topical subjects with faculty from the business world teaching principles of leadership. The program includes a mentoring action plan for participants and leads to a graduate certificate in leadership development from GWU’s Graduate School of Education and Human Development at the end of the year’s studies.

Dr. Tuck credits completing this kind of coursework for his current position of leadership in the VA and he tries to share what he has learned with the medical students he teaches.

“When I was starting out as a physician, I never received training in how to lead a team. I found myself trying to get everything done for my patients while teaching my learners, and I really struggled for the first couple of years to manage these competing demands on my time,” he said.

Now, on the first day of a new clinical rotation, he meets one-on-one with his residents to set out goals and expectations. “I say: ‘This is how I want rounds to be run. What are your expectations?’ That way we make sure we’re collaborating as a team. I don’t know that medical school prepares you for this kind of teamwork. Unless you bring a background in business, you can really struggle.”
 

Interest in hospital medicine

“Throughout our medical training we do a variety of rotations and clerkships. I found myself falling in love with all of them – surgery, psychiatry, obstetrics, and gynecology,” Dr. Tuck explained, as he reflected on how he ended up in hospital medicine. “As someone who was interested in all of these different fields of medicine, I considered myself a true medical generalist. And in hospitalized patients, who struggle with all of the different issues that bring them to the hospital, I saw a compilation of all my experiences in residency training combined in one setting.”

Hospital medicine was a relatively young field at that time, with few academic hospitalists, he said. “But I had good mentors who encouraged me to pursue my educational, research, and administrative interests. My affinity for the VA was also largely due to my training. We worked in multiple settings – academic, community-based, National Institutes of Health, and at the VA.”

Dr. Tuck said that, of all the settings in which he practiced, he felt the VA truly trained him best to be a doctor. “The experience made me feel like a holistic practitioner,” he said. “The system allowed me to take the best care of my patients, since I didn’t have to worry about whether I could make needed referrals to specialists. Very early in my internship year we were seeing very sick patients with multiple comorbidities, but it was easy to get a social worker or case manager involved, compared to other settings, which can be more difficult to navigate.”

While the VA is a “great health system,” Dr. Tuck said, the challenge is learning how to work with its bureaucracy. “If you don’t know how the system works, it can seem to get in your way.” But overall, he said, the VA functions well and compares favorably with private sector hospitals and health systems. That was also the conclusion of a recent study in the Journal of General Internal Medicine, which compared the quality of outpatient and inpatient care in VA and non-VA settings using recent performance measure data.¹ The authors concluded that the VA system performed similarly or better than non-VA health care on most nationally recognized measures of inpatient and outpatient care quality, although there is wide variation between VA facilities.
 

Working with the team

Another major interest for Dr. Tuck is team-based learning, which also grew out of his GWU leadership certificate course work on teaching teams and team development. He is working on a draft paper for publication with coauthor Patrick Rendon, MD, associate program director for the University of New Mexico’s internal medicine residency program, building on the group development stage theory – “Forming/Storming/Norming/Performing” – developed by Tuckman and Jenson.²

The theory offers 12 tips for optimizing inpatient ward team performance, such as getting the learners to buy in at an early stage of a project. “Everyone I talk to about our research is eager to learn how to apply these principles. I don’t think we’re unique at this center. We’re constantly rotating learners through the program. If you apply these principles, you can get learners to be more efficient starting from the first day,” he said.

The current inpatient team model at the Washington VAMC involves a broadly representative team from nursing, case management, social work, the business office, medical coding, utilization management, and administration that convenes every morning to discuss patient navigation and difficult discharges. “Everyone sits around a big table, and the six hospital medicine teams rotate through every fifteen minutes to review their patients’ admitting diagnoses, barriers to discharge and plans of care.”

At the patient’s bedside, a Focused Interdisciplinary Team (FIT) model, which Dr. Tuck helped to implement, incorporates a four-step process with clearly defined roles for the attending, nurse, pharmacist, and case manager or social worker. “Since implementation, our data show overall reductions in lengths of stay,” he said.

Dr. Tuck urges other hospitalists to pursue opportunities available to them to develop their leadership skills. “Look to your professional societies such as the Society of General Internal Medicine (SGIM) or SHM.” For example, SGIM’s Academic Hospitalist Commission, which he cochairs, provides a voice on the national stage for academic hospitalists and cosponsors with SHM an annual Academic Hospitalist Academy to support career development for junior academic hospitalists as educational leaders. Since 2016, its Distinguished Professor of Hospital Medicine recognizes a professor of hospital medicine to give a plenary address at the SGIM national meeting.

SGIM’s SCHOLAR Project, a subgroup of its Academic Hospitalist Commission, has worked to identify features of successful academic hospitalist programs, with the results published in the Journal of Hospital Medicine.³

“We learned that what sets successful programs apart is their leadership – as well as protected time for scholarly pursuits,” he said. “We’re all leaders in this field, whether we view ourselves that way or not.”

References

1. Price RA et al. Comparing quality of care in Veterans Affairs and Non–Veterans Affairs settings. J Gen Intern Med. 2018 Oct;33(10):1631-38.

2. Tuckman B, Jensen M. Stages of small group development revisited. Group and Organizational Studies. 1977;2:419-427.

3. Seymann GB et al. Features of successful academic hospitalist programs: Insights from the SCHOLAR (Successful hospitalists in academics and research) project. J Hosp Med. 2016 Oct;11(10):708-13.

For Matthew Tuck, MD, MEd, FACP, associate section chief for hospital medicine at the Veterans Affairs Medical Center (VAMC) in Washington, leadership is something that hospitalists can and should be learning at every opportunity.

Some of the best insights about effective leadership, teamwork, and process improvement come from the business world and have been slower to infiltrate into hospital settings and hospitalist groups, he says. But Dr. Tuck has tried to take advantage of numerous opportunities for leadership development in his own career.

He has been a hospitalist since 2010 and is part of a group of 13 physicians, all of whom carry clinical, teaching, and research responsibilities while pursuing a variety of education, quality improvement, and performance improvement topics.

“My chair has been generous about giving me time to do teaching and research and to pursue opportunities for career development,” he said. The Washington VAMC works with four affiliate medical schools in the area, and its six daily hospital medicine services are all 100% teaching services with assigned residents and interns.

Dr. Tuck divides his professional time roughly one-third each between clinical – seeing patients 5 months a year on a consultative or inpatient basis with resident teams; administrative in a variety of roles; and research. He has academic appointments at the George Washington University (GWU) School of Medicine and at the Uniformed Services University of Health Sciences in Bethesda, Md. He developed the coursework for teaching evidence-based medicine to first- and second-year medical students at GWU.

He is also part of a large research consortium with five sites and $7.5 million in funding over 5 years from NIH’s National Institute on Minority Health and Health Disparities to study how genetic information from African American patients can predict their response to cardiovascular medications. He serves as the study’s site Principal Investigator at the VAMC.

Opportunities to advance his leadership skills have included the VA’s Aspiring Leaders Program and Leadership Development Mentoring Program, which teach leadership skills on topical subjects such as teaching, communications skills, and finance. The Master Teacher Leadership Development Program for medical faculty at GWU, where he attended medical school and did his internship and residency, offers six intensive, classroom-based 8-week courses over a 1-year period. They cover various topical subjects with faculty from the business world teaching principles of leadership. The program includes a mentoring action plan for participants and leads to a graduate certificate in leadership development from GWU’s Graduate School of Education and Human Development at the end of the year’s studies.

Dr. Tuck credits completing this kind of coursework for his current position of leadership in the VA and he tries to share what he has learned with the medical students he teaches.

“When I was starting out as a physician, I never received training in how to lead a team. I found myself trying to get everything done for my patients while teaching my learners, and I really struggled for the first couple of years to manage these competing demands on my time,” he said.

Now, on the first day of a new clinical rotation, he meets one-on-one with his residents to set out goals and expectations. “I say: ‘This is how I want rounds to be run. What are your expectations?’ That way we make sure we’re collaborating as a team. I don’t know that medical school prepares you for this kind of teamwork. Unless you bring a background in business, you can really struggle.”
 

Interest in hospital medicine

“Throughout our medical training we do a variety of rotations and clerkships. I found myself falling in love with all of them – surgery, psychiatry, obstetrics, and gynecology,” Dr. Tuck explained, as he reflected on how he ended up in hospital medicine. “As someone who was interested in all of these different fields of medicine, I considered myself a true medical generalist. And in hospitalized patients, who struggle with all of the different issues that bring them to the hospital, I saw a compilation of all my experiences in residency training combined in one setting.”

Hospital medicine was a relatively young field at that time, with few academic hospitalists, he said. “But I had good mentors who encouraged me to pursue my educational, research, and administrative interests. My affinity for the VA was also largely due to my training. We worked in multiple settings – academic, community-based, National Institutes of Health, and at the VA.”

Dr. Tuck said that, of all the settings in which he practiced, he felt the VA truly trained him best to be a doctor. “The experience made me feel like a holistic practitioner,” he said. “The system allowed me to take the best care of my patients, since I didn’t have to worry about whether I could make needed referrals to specialists. Very early in my internship year we were seeing very sick patients with multiple comorbidities, but it was easy to get a social worker or case manager involved, compared to other settings, which can be more difficult to navigate.”

While the VA is a “great health system,” Dr. Tuck said, the challenge is learning how to work with its bureaucracy. “If you don’t know how the system works, it can seem to get in your way.” But overall, he said, the VA functions well and compares favorably with private sector hospitals and health systems. That was also the conclusion of a recent study in the Journal of General Internal Medicine, which compared the quality of outpatient and inpatient care in VA and non-VA settings using recent performance measure data.¹ The authors concluded that the VA system performed similarly or better than non-VA health care on most nationally recognized measures of inpatient and outpatient care quality, although there is wide variation between VA facilities.
 

Working with the team

Another major interest for Dr. Tuck is team-based learning, which also grew out of his GWU leadership certificate course work on teaching teams and team development. He is working on a draft paper for publication with coauthor Patrick Rendon, MD, associate program director for the University of New Mexico’s internal medicine residency program, building on the group development stage theory – “Forming/Storming/Norming/Performing” – developed by Tuckman and Jenson.²

The theory offers 12 tips for optimizing inpatient ward team performance, such as getting the learners to buy in at an early stage of a project. “Everyone I talk to about our research is eager to learn how to apply these principles. I don’t think we’re unique at this center. We’re constantly rotating learners through the program. If you apply these principles, you can get learners to be more efficient starting from the first day,” he said.

The current inpatient team model at the Washington VAMC involves a broadly representative team from nursing, case management, social work, the business office, medical coding, utilization management, and administration that convenes every morning to discuss patient navigation and difficult discharges. “Everyone sits around a big table, and the six hospital medicine teams rotate through every fifteen minutes to review their patients’ admitting diagnoses, barriers to discharge and plans of care.”

At the patient’s bedside, a Focused Interdisciplinary Team (FIT) model, which Dr. Tuck helped to implement, incorporates a four-step process with clearly defined roles for the attending, nurse, pharmacist, and case manager or social worker. “Since implementation, our data show overall reductions in lengths of stay,” he said.

Dr. Tuck urges other hospitalists to pursue opportunities available to them to develop their leadership skills. “Look to your professional societies such as the Society of General Internal Medicine (SGIM) or SHM.” For example, SGIM’s Academic Hospitalist Commission, which he cochairs, provides a voice on the national stage for academic hospitalists and cosponsors with SHM an annual Academic Hospitalist Academy to support career development for junior academic hospitalists as educational leaders. Since 2016, its Distinguished Professor of Hospital Medicine recognizes a professor of hospital medicine to give a plenary address at the SGIM national meeting.

SGIM’s SCHOLAR Project, a subgroup of its Academic Hospitalist Commission, has worked to identify features of successful academic hospitalist programs, with the results published in the Journal of Hospital Medicine.³

“We learned that what sets successful programs apart is their leadership – as well as protected time for scholarly pursuits,” he said. “We’re all leaders in this field, whether we view ourselves that way or not.”

References

1. Price RA et al. Comparing quality of care in Veterans Affairs and Non–Veterans Affairs settings. J Gen Intern Med. 2018 Oct;33(10):1631-38.

2. Tuckman B, Jensen M. Stages of small group development revisited. Group and Organizational Studies. 1977;2:419-427.

3. Seymann GB et al. Features of successful academic hospitalist programs: Insights from the SCHOLAR (Successful hospitalists in academics and research) project. J Hosp Med. 2016 Oct;11(10):708-13.

Counties in states that expanded Medicaid coverage under the Affordable Care Act have experienced a significantly smaller increase in cardiovascular mortality rates among middle-aged adults, compared with counties in states that did not expand coverage, according to findings from a new study.

In expansion-state counties, the change in cardiovascular mortality was stable between the pre-expansion (2010-2013) and postexpansion (2014-2016) periods, at 146.5-146.4 deaths per 100,000 residents per year, compared with mortality rates in nonexpansion counties during the same periods (176.3-180.9 deaths per 100,000), Sameed Ahmed M. Khatana, MD, and colleagues wrote in JAMA Cardiology.

“After accounting for demographic, clinical, and economic differences, counties in expansion states had 4.3 fewer deaths per 100,000 residents per year from cardiovascular causes after Medicaid expansion than if they had followed the same trends as counties in nonexpansion states,” Dr. Khatana, of the University of Pennsylvania, Philadelphia, and colleagues wrote..

That translated into 2,039 fewer total deaths per year in residents aged between 45 and 64 years from cardiovascular causes after Medicaid expansion, the authors noted.

In all, 29 states, plus Washington, D.C., were included in the expansion group, and 19 states were in the nonexpansion (control) group. During the study period, from 2010 to 2016, the number of expansion counties ranged between 912 and 931, and for the nonexpansion counties, between 985 and 1,029. About half of the residents in each group were women. The percentage of black residents was lower in expansion states, but the percentage of Hispanic residents did not differ. Compared with nonexpansion counties, expansion counties also had a lower prevalence of diabetes (8.5% vs. 9.7% in the nonexpansion counties), obesity (26.2% vs. 29.1%), and smoking (17.1 vs. 18.9%); a lower mean percentage of poor residents (14.4% vs 16.6%; all with P less than .001); and a higher median household income.

Expansion counties also fared better when it came to health insurance coverage. In 2010, 14.6% of their residents had no coverage, compared with 19.5% of residents in nonexpansion counties. During the study period, the decrease in the percentage of middle-aged residents without health coverage was larger in expansion than in nonexpansion counties (7.3% vs. 5.6%, respectively), as was the decrease in low-income residents without coverage (19.8% vs. 13.5%).

However, the authors cautioned that, given the observational nature of the study, they were “not able to make a causal association between expansion of Medicaid eligibility and differences in the cardiovascular mortality rates between the two groups of counties. It is possible that there were other unmeasured time varying factors that can explain the observed association.”

Despite that limitation of the study, which observed adults in all income categories and was not limited to low-income residents, the researchers noted that, given the association between Medicaid expansion and cardiovascular mortality rates, as well as the “high burden of cardiovascular risk factors among individuals without insurance and those with lower socioeconomic status,” policy makers might consider the results in future discussions about changes to eligibility for and expansion of Medicaid.

Dr. Khatana is supported by a grant from the National Institutes of Health. Two authors reported relationships with drug companies outside of the reported study; the rest of the authors had no disclosures to report.

SOURCE: Khatana SAM et al. JAMA Cardiol. 2019 Jun 5. doi: 10.1001/jamacardio.2019.1651.

Counties in states that expanded Medicaid coverage under the Affordable Care Act have experienced a significantly smaller increase in cardiovascular mortality rates among middle-aged adults, compared with counties in states that did not expand coverage, according to findings from a new study.

In expansion-state counties, the change in cardiovascular mortality was stable between the pre-expansion (2010-2013) and postexpansion (2014-2016) periods, at 146.5-146.4 deaths per 100,000 residents per year, compared with mortality rates in nonexpansion counties during the same periods (176.3-180.9 deaths per 100,000), Sameed Ahmed M. Khatana, MD, and colleagues wrote in JAMA Cardiology.

“After accounting for demographic, clinical, and economic differences, counties in expansion states had 4.3 fewer deaths per 100,000 residents per year from cardiovascular causes after Medicaid expansion than if they had followed the same trends as counties in nonexpansion states,” Dr. Khatana, of the University of Pennsylvania, Philadelphia, and colleagues wrote..

That translated into 2,039 fewer total deaths per year in residents aged between 45 and 64 years from cardiovascular causes after Medicaid expansion, the authors noted.

In all, 29 states, plus Washington, D.C., were included in the expansion group, and 19 states were in the nonexpansion (control) group. During the study period, from 2010 to 2016, the number of expansion counties ranged between 912 and 931, and for the nonexpansion counties, between 985 and 1,029. About half of the residents in each group were women. The percentage of black residents was lower in expansion states, but the percentage of Hispanic residents did not differ. Compared with nonexpansion counties, expansion counties also had a lower prevalence of diabetes (8.5% vs. 9.7% in the nonexpansion counties), obesity (26.2% vs. 29.1%), and smoking (17.1 vs. 18.9%); a lower mean percentage of poor residents (14.4% vs 16.6%; all with P less than .001); and a higher median household income.

Expansion counties also fared better when it came to health insurance coverage. In 2010, 14.6% of their residents had no coverage, compared with 19.5% of residents in nonexpansion counties. During the study period, the decrease in the percentage of middle-aged residents without health coverage was larger in expansion than in nonexpansion counties (7.3% vs. 5.6%, respectively), as was the decrease in low-income residents without coverage (19.8% vs. 13.5%).

However, the authors cautioned that, given the observational nature of the study, they were “not able to make a causal association between expansion of Medicaid eligibility and differences in the cardiovascular mortality rates between the two groups of counties. It is possible that there were other unmeasured time varying factors that can explain the observed association.”

Despite that limitation of the study, which observed adults in all income categories and was not limited to low-income residents, the researchers noted that, given the association between Medicaid expansion and cardiovascular mortality rates, as well as the “high burden of cardiovascular risk factors among individuals without insurance and those with lower socioeconomic status,” policy makers might consider the results in future discussions about changes to eligibility for and expansion of Medicaid.

Dr. Khatana is supported by a grant from the National Institutes of Health. Two authors reported relationships with drug companies outside of the reported study; the rest of the authors had no disclosures to report.

SOURCE: Khatana SAM et al. JAMA Cardiol. 2019 Jun 5. doi: 10.1001/jamacardio.2019.1651.

Counties in states that expanded Medicaid coverage under the Affordable Care Act have experienced a significantly smaller increase in cardiovascular mortality rates among middle-aged adults, compared with counties in states that did not expand coverage, according to findings from a new study.

In expansion-state counties, the change in cardiovascular mortality was stable between the pre-expansion (2010-2013) and postexpansion (2014-2016) periods, at 146.5-146.4 deaths per 100,000 residents per year, compared with mortality rates in nonexpansion counties during the same periods (176.3-180.9 deaths per 100,000), Sameed Ahmed M. Khatana, MD, and colleagues wrote in JAMA Cardiology.

“After accounting for demographic, clinical, and economic differences, counties in expansion states had 4.3 fewer deaths per 100,000 residents per year from cardiovascular causes after Medicaid expansion than if they had followed the same trends as counties in nonexpansion states,” Dr. Khatana, of the University of Pennsylvania, Philadelphia, and colleagues wrote..

That translated into 2,039 fewer total deaths per year in residents aged between 45 and 64 years from cardiovascular causes after Medicaid expansion, the authors noted.

In all, 29 states, plus Washington, D.C., were included in the expansion group, and 19 states were in the nonexpansion (control) group. During the study period, from 2010 to 2016, the number of expansion counties ranged between 912 and 931, and for the nonexpansion counties, between 985 and 1,029. About half of the residents in each group were women. The percentage of black residents was lower in expansion states, but the percentage of Hispanic residents did not differ. Compared with nonexpansion counties, expansion counties also had a lower prevalence of diabetes (8.5% vs. 9.7% in the nonexpansion counties), obesity (26.2% vs. 29.1%), and smoking (17.1 vs. 18.9%); a lower mean percentage of poor residents (14.4% vs 16.6%; all with P less than .001); and a higher median household income.

Expansion counties also fared better when it came to health insurance coverage. In 2010, 14.6% of their residents had no coverage, compared with 19.5% of residents in nonexpansion counties. During the study period, the decrease in the percentage of middle-aged residents without health coverage was larger in expansion than in nonexpansion counties (7.3% vs. 5.6%, respectively), as was the decrease in low-income residents without coverage (19.8% vs. 13.5%).

However, the authors cautioned that, given the observational nature of the study, they were “not able to make a causal association between expansion of Medicaid eligibility and differences in the cardiovascular mortality rates between the two groups of counties. It is possible that there were other unmeasured time varying factors that can explain the observed association.”

Despite that limitation of the study, which observed adults in all income categories and was not limited to low-income residents, the researchers noted that, given the association between Medicaid expansion and cardiovascular mortality rates, as well as the “high burden of cardiovascular risk factors among individuals without insurance and those with lower socioeconomic status,” policy makers might consider the results in future discussions about changes to eligibility for and expansion of Medicaid.

Dr. Khatana is supported by a grant from the National Institutes of Health. Two authors reported relationships with drug companies outside of the reported study; the rest of the authors had no disclosures to report.

SOURCE: Khatana SAM et al. JAMA Cardiol. 2019 Jun 5. doi: 10.1001/jamacardio.2019.1651.

“No hassle” new manuscript submission process

Many authors have experienced the frustration of formatting a manuscript for submission to a medical journal. The process is time consuming and each journal has different requirements. This means that if you decide to submit your manuscript to one journal and later decide that another journal is a better fit, you may spend an hour (or several hours) reformatting to meet the new journal’s unique requirements.

To allow authors to spend more time on what matters to them, we’re pleased to introduce our “No Hassle” process for initial original research and brief report manuscript submissions to the Journal of Hospital Medicine. Our goal is to eliminate unnecessary and burdensome steps in the manuscript submission process. Thus, we have relaxed formatting requirements for initial manuscript submissions. Any conventional and readable manuscript format and reference style is acceptable.

Tables and figures can be embedded in the main document file or uploaded individually, depending on your preference. Funding and disclosures should be included on the title page but there is no need to submit completed disclosure or copyright forms unless we request a manuscript revision.
 

Timely decisions

We have all experienced the agony of waiting months on end for a journal to make a decision about our manuscript. The review process itself can take many months (or even longer). Furthermore, a manuscript may not be published for many more months (or even longer) following acceptance. At the Journal of Hospital Medicine, we commit to making timely decisions and publishing your accepted manuscript as fast as we can.

We currently reject approximately half of all original research and brief report manuscript submissions without formal peer review. We do this for two reasons. First, we want to ensure that we’re not overburdening our peer reviewers so we only ask them to review manuscripts that we are seriously considering for publication. Second, we want to ensure that we’re being respectful of our authors’ time. If we are unlikely to publish a manuscript based on lower priority scores assigned by me, as editor-in-chief, or other journal editors, we don’t want to subject your manuscript to a lengthy peer review, but would rather return the manuscript to you quickly for timely submission elsewhere.

Here are data that support our timely decision making:

• 1.3 days = our average time from manuscript submission to rejection without formal peer review (median, less than one day).
• 23 days = our average time from manuscript submission to first decision for manuscripts sent for peer review.

We also are working to improve our time to publication. Our goal is to publish accepted manuscripts within 120 days from initial submission to publication, and within 60 days from acceptance to publication.
 

Dissemination

Finally, little public knowledge is gleaned from medical research unless the study is published and widely read. The Journal of Hospital Medicine is at the leading edge of helping authors disseminate their work to a broader audience. Of course, we produce press releases and distribute those to many media outlets in partnership with the Society of Hospital Medicine. We also leverage social media to promote your article through tweets, visual abstracts, and, more recently, comics or graphic medicine abstracts. Some articles are even discussed on #JHMChat, our twitter-based journal club. This work is led by our exceptional Digital Media Editors, Dr. Vineet Arora (@FutureDocs), Dr. Charlie Wray (@WrayCharles), and Dr. Grace Farris (@gracefarris).

In summary, we are committed to making the Journal of Hospital Medicine even more author friendly. To that end, we’re making it easy for authors to submit their work, making timely disposition decisions, and facilitating dissemination of the work we publish.
 

Dr. Shah is chief metrics officer and director of the division of hospital medicine at Cincinnati Children’s Hospital Medical Center. He is the current editor-in-chief of the Journal of Hospital Medicine.

“No hassle” new manuscript submission process

Many authors have experienced the frustration of formatting a manuscript for submission to a medical journal. The process is time consuming and each journal has different requirements. This means that if you decide to submit your manuscript to one journal and later decide that another journal is a better fit, you may spend an hour (or several hours) reformatting to meet the new journal’s unique requirements.

To allow authors to spend more time on what matters to them, we’re pleased to introduce our “No Hassle” process for initial original research and brief report manuscript submissions to the Journal of Hospital Medicine. Our goal is to eliminate unnecessary and burdensome steps in the manuscript submission process. Thus, we have relaxed formatting requirements for initial manuscript submissions. Any conventional and readable manuscript format and reference style is acceptable.

Tables and figures can be embedded in the main document file or uploaded individually, depending on your preference. Funding and disclosures should be included on the title page but there is no need to submit completed disclosure or copyright forms unless we request a manuscript revision.
 

Timely decisions

We have all experienced the agony of waiting months on end for a journal to make a decision about our manuscript. The review process itself can take many months (or even longer). Furthermore, a manuscript may not be published for many more months (or even longer) following acceptance. At the Journal of Hospital Medicine, we commit to making timely decisions and publishing your accepted manuscript as fast as we can.

We currently reject approximately half of all original research and brief report manuscript submissions without formal peer review. We do this for two reasons. First, we want to ensure that we’re not overburdening our peer reviewers so we only ask them to review manuscripts that we are seriously considering for publication. Second, we want to ensure that we’re being respectful of our authors’ time. If we are unlikely to publish a manuscript based on lower priority scores assigned by me, as editor-in-chief, or other journal editors, we don’t want to subject your manuscript to a lengthy peer review, but would rather return the manuscript to you quickly for timely submission elsewhere.

Here are data that support our timely decision making:

• 1.3 days = our average time from manuscript submission to rejection without formal peer review (median, less than one day).
• 23 days = our average time from manuscript submission to first decision for manuscripts sent for peer review.

We also are working to improve our time to publication. Our goal is to publish accepted manuscripts within 120 days from initial submission to publication, and within 60 days from acceptance to publication.
 

Dissemination

Finally, little public knowledge is gleaned from medical research unless the study is published and widely read. The Journal of Hospital Medicine is at the leading edge of helping authors disseminate their work to a broader audience. Of course, we produce press releases and distribute those to many media outlets in partnership with the Society of Hospital Medicine. We also leverage social media to promote your article through tweets, visual abstracts, and, more recently, comics or graphic medicine abstracts. Some articles are even discussed on #JHMChat, our twitter-based journal club. This work is led by our exceptional Digital Media Editors, Dr. Vineet Arora (@FutureDocs), Dr. Charlie Wray (@WrayCharles), and Dr. Grace Farris (@gracefarris).

In summary, we are committed to making the Journal of Hospital Medicine even more author friendly. To that end, we’re making it easy for authors to submit their work, making timely disposition decisions, and facilitating dissemination of the work we publish.
 

Dr. Shah is chief metrics officer and director of the division of hospital medicine at Cincinnati Children’s Hospital Medical Center. He is the current editor-in-chief of the Journal of Hospital Medicine.

“No hassle” new manuscript submission process

Many authors have experienced the frustration of formatting a manuscript for submission to a medical journal. The process is time consuming and each journal has different requirements. This means that if you decide to submit your manuscript to one journal and later decide that another journal is a better fit, you may spend an hour (or several hours) reformatting to meet the new journal’s unique requirements.

To allow authors to spend more time on what matters to them, we’re pleased to introduce our “No Hassle” process for initial original research and brief report manuscript submissions to the Journal of Hospital Medicine. Our goal is to eliminate unnecessary and burdensome steps in the manuscript submission process. Thus, we have relaxed formatting requirements for initial manuscript submissions. Any conventional and readable manuscript format and reference style is acceptable.

Tables and figures can be embedded in the main document file or uploaded individually, depending on your preference. Funding and disclosures should be included on the title page but there is no need to submit completed disclosure or copyright forms unless we request a manuscript revision.
 

Timely decisions

We have all experienced the agony of waiting months on end for a journal to make a decision about our manuscript. The review process itself can take many months (or even longer). Furthermore, a manuscript may not be published for many more months (or even longer) following acceptance. At the Journal of Hospital Medicine, we commit to making timely decisions and publishing your accepted manuscript as fast as we can.

We currently reject approximately half of all original research and brief report manuscript submissions without formal peer review. We do this for two reasons. First, we want to ensure that we’re not overburdening our peer reviewers so we only ask them to review manuscripts that we are seriously considering for publication. Second, we want to ensure that we’re being respectful of our authors’ time. If we are unlikely to publish a manuscript based on lower priority scores assigned by me, as editor-in-chief, or other journal editors, we don’t want to subject your manuscript to a lengthy peer review, but would rather return the manuscript to you quickly for timely submission elsewhere.

Here are data that support our timely decision making:

• 1.3 days = our average time from manuscript submission to rejection without formal peer review (median, less than one day).
• 23 days = our average time from manuscript submission to first decision for manuscripts sent for peer review.

We also are working to improve our time to publication. Our goal is to publish accepted manuscripts within 120 days from initial submission to publication, and within 60 days from acceptance to publication.
 

Dissemination

Finally, little public knowledge is gleaned from medical research unless the study is published and widely read. The Journal of Hospital Medicine is at the leading edge of helping authors disseminate their work to a broader audience. Of course, we produce press releases and distribute those to many media outlets in partnership with the Society of Hospital Medicine. We also leverage social media to promote your article through tweets, visual abstracts, and, more recently, comics or graphic medicine abstracts. Some articles are even discussed on #JHMChat, our twitter-based journal club. This work is led by our exceptional Digital Media Editors, Dr. Vineet Arora (@FutureDocs), Dr. Charlie Wray (@WrayCharles), and Dr. Grace Farris (@gracefarris).

In summary, we are committed to making the Journal of Hospital Medicine even more author friendly. To that end, we’re making it easy for authors to submit their work, making timely disposition decisions, and facilitating dissemination of the work we publish.
 

Dr. Shah is chief metrics officer and director of the division of hospital medicine at Cincinnati Children’s Hospital Medical Center. He is the current editor-in-chief of the Journal of Hospital Medicine.

Lipoprotein(a) is an independent risk factor for atherosclerotic cardiovascular disease–related events, and plasma levels of Lp(a) could help refine risk assessment and influence treatment decisions, say the authors of a scientific statement from the National Lipid Association.

Don P. Wilson, MD, of Cook Children’s Medical Center, Fort Worth, Tex., and coauthors reviewed the evidence around testing of Lp(a) in clinical practice and its use in guiding treatment for both primary and secondary prevention. Their report is in the Journal of Clinical Lipidology.

Prospective, population-based studies point to a clear link between high Lp(a) levels and high risk of myocardial infarction, coronary heart disease, coronary artery stenosis, carotid stenosis, valvular aortic stenosis, ischemic stroke, cardiovascular mortality, and all-cause mortality, the authors wrote. This association was independent of the effect of other risk factors, including LDL cholesterol.

However, existing Lp(a) assays have not been globally standardized, and there is only incomplete evidence for age, sex, or ethnicity-specific cutoff points for high risk.

The authors suggested Lp(a) levels greater than 50 mg/dL (100 nmol/L) could be considered a risk factor that justifies the initiation of statin therapy. However ,they pointed out this level corresponded to the 80th population percentile in predominantly white populations, while in African American populations the equivalent cutoff was around 150 nmol/L.

On the issue of whom to test for Lp(a) serum levels, the authors said testing could reasonably be used to refine risk assessment for atherosclerotic cardiovascular disease in adults with first-degree relatives who experienced premature atherosclerotic cardiovascular disease, those with a personal history of the disease, or in those with severe hypercholesterolemia or suspected familial hypercholesterolemia.

However, statin therapy does not decrease Lp(a) levels, and there is also evidence that patients with high Lp(a) levels may not show as much LDL-C lowering in response to statin therapy.

“There is a lack of current evidence demonstrating that lowering Lp(a), independently of LDL-C, reduces ASCVD events in individuals with established ASCVD,” the authors wrote. “It appears that large absolute reductions in Lp(a) may be needed to demonstrate a significant clinical benefit.”

Despite this, the authors argued that in primary prevention, it was reasonable to use a Lp(a) level greater than 50 mg/dL (100 nmol/L) as a “risk-enhancing factor,” and in high-risk or very-high-risk patients with elevated LDL-C, it could prompt use of more intensive therapies.

Five authors disclosed honorarium or advisory board positions with the pharmaceutical sector. No other conflicts of interest were declared.

SOURCE: Wilson D et al. J Clin Lipidol. 2019 May 17. doi: 10.1016/j.jacl.2019.04.010.

Lipoprotein(a) is an independent risk factor for atherosclerotic cardiovascular disease–related events, and plasma levels of Lp(a) could help refine risk assessment and influence treatment decisions, say the authors of a scientific statement from the National Lipid Association.

Don P. Wilson, MD, of Cook Children’s Medical Center, Fort Worth, Tex., and coauthors reviewed the evidence around testing of Lp(a) in clinical practice and its use in guiding treatment for both primary and secondary prevention. Their report is in the Journal of Clinical Lipidology.

Prospective, population-based studies point to a clear link between high Lp(a) levels and high risk of myocardial infarction, coronary heart disease, coronary artery stenosis, carotid stenosis, valvular aortic stenosis, ischemic stroke, cardiovascular mortality, and all-cause mortality, the authors wrote. This association was independent of the effect of other risk factors, including LDL cholesterol.

However, existing Lp(a) assays have not been globally standardized, and there is only incomplete evidence for age, sex, or ethnicity-specific cutoff points for high risk.

The authors suggested Lp(a) levels greater than 50 mg/dL (100 nmol/L) could be considered a risk factor that justifies the initiation of statin therapy. However ,they pointed out this level corresponded to the 80th population percentile in predominantly white populations, while in African American populations the equivalent cutoff was around 150 nmol/L.

On the issue of whom to test for Lp(a) serum levels, the authors said testing could reasonably be used to refine risk assessment for atherosclerotic cardiovascular disease in adults with first-degree relatives who experienced premature atherosclerotic cardiovascular disease, those with a personal history of the disease, or in those with severe hypercholesterolemia or suspected familial hypercholesterolemia.

However, statin therapy does not decrease Lp(a) levels, and there is also evidence that patients with high Lp(a) levels may not show as much LDL-C lowering in response to statin therapy.

“There is a lack of current evidence demonstrating that lowering Lp(a), independently of LDL-C, reduces ASCVD events in individuals with established ASCVD,” the authors wrote. “It appears that large absolute reductions in Lp(a) may be needed to demonstrate a significant clinical benefit.”

Despite this, the authors argued that in primary prevention, it was reasonable to use a Lp(a) level greater than 50 mg/dL (100 nmol/L) as a “risk-enhancing factor,” and in high-risk or very-high-risk patients with elevated LDL-C, it could prompt use of more intensive therapies.

Five authors disclosed honorarium or advisory board positions with the pharmaceutical sector. No other conflicts of interest were declared.

SOURCE: Wilson D et al. J Clin Lipidol. 2019 May 17. doi: 10.1016/j.jacl.2019.04.010.

Lipoprotein(a) is an independent risk factor for atherosclerotic cardiovascular disease–related events, and plasma levels of Lp(a) could help refine risk assessment and influence treatment decisions, say the authors of a scientific statement from the National Lipid Association.

Don P. Wilson, MD, of Cook Children’s Medical Center, Fort Worth, Tex., and coauthors reviewed the evidence around testing of Lp(a) in clinical practice and its use in guiding treatment for both primary and secondary prevention. Their report is in the Journal of Clinical Lipidology.

Prospective, population-based studies point to a clear link between high Lp(a) levels and high risk of myocardial infarction, coronary heart disease, coronary artery stenosis, carotid stenosis, valvular aortic stenosis, ischemic stroke, cardiovascular mortality, and all-cause mortality, the authors wrote. This association was independent of the effect of other risk factors, including LDL cholesterol.

However, existing Lp(a) assays have not been globally standardized, and there is only incomplete evidence for age, sex, or ethnicity-specific cutoff points for high risk.

The authors suggested Lp(a) levels greater than 50 mg/dL (100 nmol/L) could be considered a risk factor that justifies the initiation of statin therapy. However ,they pointed out this level corresponded to the 80th population percentile in predominantly white populations, while in African American populations the equivalent cutoff was around 150 nmol/L.

On the issue of whom to test for Lp(a) serum levels, the authors said testing could reasonably be used to refine risk assessment for atherosclerotic cardiovascular disease in adults with first-degree relatives who experienced premature atherosclerotic cardiovascular disease, those with a personal history of the disease, or in those with severe hypercholesterolemia or suspected familial hypercholesterolemia.

However, statin therapy does not decrease Lp(a) levels, and there is also evidence that patients with high Lp(a) levels may not show as much LDL-C lowering in response to statin therapy.

“There is a lack of current evidence demonstrating that lowering Lp(a), independently of LDL-C, reduces ASCVD events in individuals with established ASCVD,” the authors wrote. “It appears that large absolute reductions in Lp(a) may be needed to demonstrate a significant clinical benefit.”

Despite this, the authors argued that in primary prevention, it was reasonable to use a Lp(a) level greater than 50 mg/dL (100 nmol/L) as a “risk-enhancing factor,” and in high-risk or very-high-risk patients with elevated LDL-C, it could prompt use of more intensive therapies.

Five authors disclosed honorarium or advisory board positions with the pharmaceutical sector. No other conflicts of interest were declared.

SOURCE: Wilson D et al. J Clin Lipidol. 2019 May 17. doi: 10.1016/j.jacl.2019.04.010.

SAN FRANCISCO – The direct-acting anticoagulants, as a class, were more effective and at least as safe as warfarin in low-weight and very-low-weight patients with atrial fibrillation in an adjusted analysis of real-world outcomes data from more than 21,000 Korean patients.

Mitchel L. Zoler/MDedge News

The analysis also showed that the direct-acting oral anticoagulants (DOACs) had the best safety and efficacy on low-weight patients when used at the labeled dosages, with blunted efficacy and safety at dosages that either exceeded or fell short of labeled levels, So-Ryoung Lee, MD, said at the annual scientific sessions of the Heart Rhythm Society.

The overall superiority of DOACs by both efficacy and safety also generally extended to the subgroup of very-low-weight patients, those with weights of less than 50 kg. In this subgroup, which was 28% of the total population studied, the composite adverse event outcome occurred 33% less often among patients treated with a DOAC relative to patients treated with warfarin, a statistically significant difference, said Dr. Lee, a cardiologist at Seoul (South Korea) National University Hospital. Among all patients with weights of 60 kg (132 pounds) or less, the composite outcome occurred 34% less often in the DOAC-treated patients relative to the warfarin-treated patients, also a statistically significant difference.

Dr. Lee and colleagues used a Korean National Health Insurance database that included information on more than 600,000 adults with atrial fibrillation (AFib) as of January 2013. The researchers whittled this down to 21,678 patients who began for the first time treatment with an oral anticoagulant starting during or after January 2014; had no history of a stroke, intracranial hemorrhage, or gastrointestinal bleed; and weighed no more than 60 kg. This cohort included 7,575 (35%) who received warfarin treatment, and 14,103 (65%) who received a DOAC. Within the DOAC-treated group, 42% received rivaroxaban (Xarelto), 26% dabigatran (Pradaxa), 24% apixaban (Eliquis), and 8% edoxaban (Savaysa).


To account for baseline differences in demographics and comorbidities between the patients treated with a DOAC and those who received warfarin, Dr. Lee and her associates did propensity score adjustment, which resulted in similar cohorts of 6,692 patients treated with warfarin and 12,810 patients treated with a DOAC. The average age of these patients was 73 years, a third were men, and the average body mass index was just over 22 kg/m².

The events that the researchers tallied during follow-up through December 2016 included rates of all-cause death, ischemic stroke, intracranial hemorrhage, hospitalization for GI bleeding, hospitalization for major bleeding, and the composite of these five outcomes.

In the propensity-score adjusted full cohort of all patients who weighed 60 kg or less, the rate of each of these five outcomes, as well as the composite outcome, occurred statistically significantly less often among the DOAC-treated patients than in those on warfarin. The reductions ranged from a 41% lower incidence of ischemic stroke on DOAC treatment compared with warfarin treatment, to an 18% reduced rate of hospitalization for a GI bleed, compared with warfarin-treated patients. In the subgroup of patients who weighed less than 50 kg (110 pounds), the reductions ranged from a 41% cut in ischemic stroke on a DOAC compared with warfarin to a 24% relative reduction in the rate of hospitalization for a major bleed, a difference that just reached statistical significance. The outcome of hospitalization for a GI bleed showed no significant between-group difference among very-low-weight patients, but the rates of intracranial hemorrhage and all-cause death also showed statistically significant lower rates among DOAC-treated patients.

Nearly two-thirds of the patients on a DOAC received the label-appropriate dose of the drug, but 31% received a dosage that was below the labeled level while 4% received a dosage above the labeled level. An analysis that divided the NOAC patients by the appropriateness of their treatment dosages showed that patients on the correct dosages fared best. For example, in the total cohort of patients who weighed 60 kg or less, those on the correct DOAC dosage had a 9.1% rate of the combined endpoint. Patients on a low DOAC dosage did about as well as did the patients on warfarin, with a combined event rate of 11.6% in each of these subgroups. The worst outcomes occurred among the small number of patients on an inappropriately-high DOAC dosage, with a combined event rate of 15.4%. The researchers found a similar pattern among patients who weighed less than 50 kg.

Dr. Lee had no disclosures.

[email protected]

SOURCE: Lee SR et al. HRS 2019, Abstract S-AB30-05.

SAN FRANCISCO – The direct-acting anticoagulants, as a class, were more effective and at least as safe as warfarin in low-weight and very-low-weight patients with atrial fibrillation in an adjusted analysis of real-world outcomes data from more than 21,000 Korean patients.

Mitchel L. Zoler/MDedge News

The analysis also showed that the direct-acting oral anticoagulants (DOACs) had the best safety and efficacy on low-weight patients when used at the labeled dosages, with blunted efficacy and safety at dosages that either exceeded or fell short of labeled levels, So-Ryoung Lee, MD, said at the annual scientific sessions of the Heart Rhythm Society.

The overall superiority of DOACs by both efficacy and safety also generally extended to the subgroup of very-low-weight patients, those with weights of less than 50 kg. In this subgroup, which was 28% of the total population studied, the composite adverse event outcome occurred 33% less often among patients treated with a DOAC relative to patients treated with warfarin, a statistically significant difference, said Dr. Lee, a cardiologist at Seoul (South Korea) National University Hospital. Among all patients with weights of 60 kg (132 pounds) or less, the composite outcome occurred 34% less often in the DOAC-treated patients relative to the warfarin-treated patients, also a statistically significant difference.

Dr. Lee and colleagues used a Korean National Health Insurance database that included information on more than 600,000 adults with atrial fibrillation (AFib) as of January 2013. The researchers whittled this down to 21,678 patients who began for the first time treatment with an oral anticoagulant starting during or after January 2014; had no history of a stroke, intracranial hemorrhage, or gastrointestinal bleed; and weighed no more than 60 kg. This cohort included 7,575 (35%) who received warfarin treatment, and 14,103 (65%) who received a DOAC. Within the DOAC-treated group, 42% received rivaroxaban (Xarelto), 26% dabigatran (Pradaxa), 24% apixaban (Eliquis), and 8% edoxaban (Savaysa).


To account for baseline differences in demographics and comorbidities between the patients treated with a DOAC and those who received warfarin, Dr. Lee and her associates did propensity score adjustment, which resulted in similar cohorts of 6,692 patients treated with warfarin and 12,810 patients treated with a DOAC. The average age of these patients was 73 years, a third were men, and the average body mass index was just over 22 kg/m².

The events that the researchers tallied during follow-up through December 2016 included rates of all-cause death, ischemic stroke, intracranial hemorrhage, hospitalization for GI bleeding, hospitalization for major bleeding, and the composite of these five outcomes.

In the propensity-score adjusted full cohort of all patients who weighed 60 kg or less, the rate of each of these five outcomes, as well as the composite outcome, occurred statistically significantly less often among the DOAC-treated patients than in those on warfarin. The reductions ranged from a 41% lower incidence of ischemic stroke on DOAC treatment compared with warfarin treatment, to an 18% reduced rate of hospitalization for a GI bleed, compared with warfarin-treated patients. In the subgroup of patients who weighed less than 50 kg (110 pounds), the reductions ranged from a 41% cut in ischemic stroke on a DOAC compared with warfarin to a 24% relative reduction in the rate of hospitalization for a major bleed, a difference that just reached statistical significance. The outcome of hospitalization for a GI bleed showed no significant between-group difference among very-low-weight patients, but the rates of intracranial hemorrhage and all-cause death also showed statistically significant lower rates among DOAC-treated patients.

Nearly two-thirds of the patients on a DOAC received the label-appropriate dose of the drug, but 31% received a dosage that was below the labeled level while 4% received a dosage above the labeled level. An analysis that divided the NOAC patients by the appropriateness of their treatment dosages showed that patients on the correct dosages fared best. For example, in the total cohort of patients who weighed 60 kg or less, those on the correct DOAC dosage had a 9.1% rate of the combined endpoint. Patients on a low DOAC dosage did about as well as did the patients on warfarin, with a combined event rate of 11.6% in each of these subgroups. The worst outcomes occurred among the small number of patients on an inappropriately-high DOAC dosage, with a combined event rate of 15.4%. The researchers found a similar pattern among patients who weighed less than 50 kg.

Dr. Lee had no disclosures.

[email protected]

SOURCE: Lee SR et al. HRS 2019, Abstract S-AB30-05.

SAN FRANCISCO – The direct-acting anticoagulants, as a class, were more effective and at least as safe as warfarin in low-weight and very-low-weight patients with atrial fibrillation in an adjusted analysis of real-world outcomes data from more than 21,000 Korean patients.

Mitchel L. Zoler/MDedge News

The analysis also showed that the direct-acting oral anticoagulants (DOACs) had the best safety and efficacy on low-weight patients when used at the labeled dosages, with blunted efficacy and safety at dosages that either exceeded or fell short of labeled levels, So-Ryoung Lee, MD, said at the annual scientific sessions of the Heart Rhythm Society.

The overall superiority of DOACs by both efficacy and safety also generally extended to the subgroup of very-low-weight patients, those with weights of less than 50 kg. In this subgroup, which was 28% of the total population studied, the composite adverse event outcome occurred 33% less often among patients treated with a DOAC relative to patients treated with warfarin, a statistically significant difference, said Dr. Lee, a cardiologist at Seoul (South Korea) National University Hospital. Among all patients with weights of 60 kg (132 pounds) or less, the composite outcome occurred 34% less often in the DOAC-treated patients relative to the warfarin-treated patients, also a statistically significant difference.

Dr. Lee and colleagues used a Korean National Health Insurance database that included information on more than 600,000 adults with atrial fibrillation (AFib) as of January 2013. The researchers whittled this down to 21,678 patients who began for the first time treatment with an oral anticoagulant starting during or after January 2014; had no history of a stroke, intracranial hemorrhage, or gastrointestinal bleed; and weighed no more than 60 kg. This cohort included 7,575 (35%) who received warfarin treatment, and 14,103 (65%) who received a DOAC. Within the DOAC-treated group, 42% received rivaroxaban (Xarelto), 26% dabigatran (Pradaxa), 24% apixaban (Eliquis), and 8% edoxaban (Savaysa).


To account for baseline differences in demographics and comorbidities between the patients treated with a DOAC and those who received warfarin, Dr. Lee and her associates did propensity score adjustment, which resulted in similar cohorts of 6,692 patients treated with warfarin and 12,810 patients treated with a DOAC. The average age of these patients was 73 years, a third were men, and the average body mass index was just over 22 kg/m².

The events that the researchers tallied during follow-up through December 2016 included rates of all-cause death, ischemic stroke, intracranial hemorrhage, hospitalization for GI bleeding, hospitalization for major bleeding, and the composite of these five outcomes.

In the propensity-score adjusted full cohort of all patients who weighed 60 kg or less, the rate of each of these five outcomes, as well as the composite outcome, occurred statistically significantly less often among the DOAC-treated patients than in those on warfarin. The reductions ranged from a 41% lower incidence of ischemic stroke on DOAC treatment compared with warfarin treatment, to an 18% reduced rate of hospitalization for a GI bleed, compared with warfarin-treated patients. In the subgroup of patients who weighed less than 50 kg (110 pounds), the reductions ranged from a 41% cut in ischemic stroke on a DOAC compared with warfarin to a 24% relative reduction in the rate of hospitalization for a major bleed, a difference that just reached statistical significance. The outcome of hospitalization for a GI bleed showed no significant between-group difference among very-low-weight patients, but the rates of intracranial hemorrhage and all-cause death also showed statistically significant lower rates among DOAC-treated patients.

Nearly two-thirds of the patients on a DOAC received the label-appropriate dose of the drug, but 31% received a dosage that was below the labeled level while 4% received a dosage above the labeled level. An analysis that divided the NOAC patients by the appropriateness of their treatment dosages showed that patients on the correct dosages fared best. For example, in the total cohort of patients who weighed 60 kg or less, those on the correct DOAC dosage had a 9.1% rate of the combined endpoint. Patients on a low DOAC dosage did about as well as did the patients on warfarin, with a combined event rate of 11.6% in each of these subgroups. The worst outcomes occurred among the small number of patients on an inappropriately-high DOAC dosage, with a combined event rate of 15.4%. The researchers found a similar pattern among patients who weighed less than 50 kg.

Dr. Lee had no disclosures.

[email protected]

SOURCE: Lee SR et al. HRS 2019, Abstract S-AB30-05.