The Hospitalist

Hospital Medicine 2019 attendees outlined their key takeaways from the Updates in Acute Coronary Syndrome session, presented by Jeffrey Trost, MD, of Johns Hopkins University, Baltimore.

Vidyard Video

Dr. Trost’s discussion focused on the relationship between dual antiplatelet therapy, in-stent thrombosis, and in-stent restenosis. He also explored the diagnostic role of fractional flow reserve, and he outlined effective approaches to PCSK9 inhibitor use.

[email protected]

Hospital Medicine 2019 attendees outlined their key takeaways from the Updates in Acute Coronary Syndrome session, presented by Jeffrey Trost, MD, of Johns Hopkins University, Baltimore.

Vidyard Video

Dr. Trost’s discussion focused on the relationship between dual antiplatelet therapy, in-stent thrombosis, and in-stent restenosis. He also explored the diagnostic role of fractional flow reserve, and he outlined effective approaches to PCSK9 inhibitor use.

[email protected]

Hospital Medicine 2019 attendees outlined their key takeaways from the Updates in Acute Coronary Syndrome session, presented by Jeffrey Trost, MD, of Johns Hopkins University, Baltimore.

Vidyard Video

Dr. Trost’s discussion focused on the relationship between dual antiplatelet therapy, in-stent thrombosis, and in-stent restenosis. He also explored the diagnostic role of fractional flow reserve, and he outlined effective approaches to PCSK9 inhibitor use.

[email protected]

Our profession continues to experience steady growth, and demand for hospitalist physicians exceeds supply. In a recent article in The Hospitalist, Andrew White, MD, SFHM, highlighted the fact that most hospital medicine groups (HMGs) are constantly recruiting and open positions are not uncommon.

When we think about recruitment and staffing, I bet many of us think principally of physicians trained in the general medicine specialties of internal medicine, family medicine, and pediatrics. Yet, to help meet demand for hospital-based clinicians, HMGs sometimes turn to physicians certified in emergency medicine, critical care, geriatric medicine, palliative care, and other fields.

To gain a better understanding of the diversity within our profession, the Society of Hospital Medicine’s State of Hospital Medicine survey asked HMGs whether they employ at least one physician in these various specialties. Results published in the recently released 2018 State of Hospital Medicine (SoHM) Report show significant differences among groups, affected by location, group size, and type of employer.

At the core of our profession are physicians trained in internal medicine, present in 99.2% of adult medicine HMGs throughout the United States. No surprise given that our field was founded by internists and remains a popular career choice for IM residency graduates. Family physicians follow, with the highest percentage of groups employing at least one FP located in the southern United States at 70.3% and lowest in the west at 54.7%. Small-sized groups – fewer than 10 full-time equivalents (FTEs) – were also more likely to employ FPs.

This speaks to the challenge – often faced by smaller hospitals – of covering both adult and pediatric patient populations and limited workforce availability. Pediatrics- and internal medicine/pediatrics–trained physicians help meet this need and were prevalent within small-sized groups. Another distinction found in the report is that, while 92.1% of multistate hospitalist management companies employed family physicians, only 28.8% of academic university settings did so. Partly because of Accreditation Council for Graduate Medical Education requirements for IM-certified teaching attending for internal medicine residents, FP and other specialties are filling some non–teaching hospitalist positions within our academic programs.

What may be surprising is that emergency medicine and critical care had the largest increase in representation in hospital medicine. The two specialties showed similar growth trends, with a larger presence in the South and Midwest states and 56% of multistate hospitalist management companies employing them. Small- to medium-sized groups of up to 20 FTEs were also more likely to have physicians from these fields, with up to 44% of groups doing so. This is a significant change from 2016, when less than 3.4% of all HMGs overall had a physician certified in emergency or critical care medicine.

This finding seems to coincide with the growth in hospital medicine groups who are covering both ED and inpatient services. For small and rural hospitals, it has become necessary and beneficial to have physicians capable of covering both clinical settings.

Contrast this with geriatric medicine and palliative care. Here, we saw these two specialties to be present in our academic institutions at 26.8% and 22.5%, respectively. Large-sized HMGs were more likely to employ them, whereas their presence in multistate management groups or private multispecialty/primary care groups was quite low. Compared with our last survey in 2016, their overall prevalence in HMGs hasn’t changed significantly. Whether this will be different in the future with our aging population will be interesting to follow.

Published biannually, the SoHM report provides insight into these and other market-based dynamics that shape hospital medicine. The demand for hospital-based clinicians and the demands of acute inpatient care are leading to the broad and inclusive nature of hospital medicine. Our staffing will continue to be met not only by internal medicine and family medicine physicians but also through these other specialties joining our ranks and adding diversity to our profession.

Dr. Sites is the executive medical director of acute medicine at Providence St. Joseph Health, Oregon, and a member of SHM’s Practice Analysis Committee. She leads the hospital medicine programs and is involved in strategy development and alignment of acute inpatient medicine services at eight member hospitals. She has been a practicing hospitalist for 20 years and volunteers on medical mission trips to Guatemala annually.

Our profession continues to experience steady growth, and demand for hospitalist physicians exceeds supply. In a recent article in The Hospitalist, Andrew White, MD, SFHM, highlighted the fact that most hospital medicine groups (HMGs) are constantly recruiting and open positions are not uncommon.

When we think about recruitment and staffing, I bet many of us think principally of physicians trained in the general medicine specialties of internal medicine, family medicine, and pediatrics. Yet, to help meet demand for hospital-based clinicians, HMGs sometimes turn to physicians certified in emergency medicine, critical care, geriatric medicine, palliative care, and other fields.

To gain a better understanding of the diversity within our profession, the Society of Hospital Medicine’s State of Hospital Medicine survey asked HMGs whether they employ at least one physician in these various specialties. Results published in the recently released 2018 State of Hospital Medicine (SoHM) Report show significant differences among groups, affected by location, group size, and type of employer.

At the core of our profession are physicians trained in internal medicine, present in 99.2% of adult medicine HMGs throughout the United States. No surprise given that our field was founded by internists and remains a popular career choice for IM residency graduates. Family physicians follow, with the highest percentage of groups employing at least one FP located in the southern United States at 70.3% and lowest in the west at 54.7%. Small-sized groups – fewer than 10 full-time equivalents (FTEs) – were also more likely to employ FPs.

This speaks to the challenge – often faced by smaller hospitals – of covering both adult and pediatric patient populations and limited workforce availability. Pediatrics- and internal medicine/pediatrics–trained physicians help meet this need and were prevalent within small-sized groups. Another distinction found in the report is that, while 92.1% of multistate hospitalist management companies employed family physicians, only 28.8% of academic university settings did so. Partly because of Accreditation Council for Graduate Medical Education requirements for IM-certified teaching attending for internal medicine residents, FP and other specialties are filling some non–teaching hospitalist positions within our academic programs.

What may be surprising is that emergency medicine and critical care had the largest increase in representation in hospital medicine. The two specialties showed similar growth trends, with a larger presence in the South and Midwest states and 56% of multistate hospitalist management companies employing them. Small- to medium-sized groups of up to 20 FTEs were also more likely to have physicians from these fields, with up to 44% of groups doing so. This is a significant change from 2016, when less than 3.4% of all HMGs overall had a physician certified in emergency or critical care medicine.

This finding seems to coincide with the growth in hospital medicine groups who are covering both ED and inpatient services. For small and rural hospitals, it has become necessary and beneficial to have physicians capable of covering both clinical settings.

Contrast this with geriatric medicine and palliative care. Here, we saw these two specialties to be present in our academic institutions at 26.8% and 22.5%, respectively. Large-sized HMGs were more likely to employ them, whereas their presence in multistate management groups or private multispecialty/primary care groups was quite low. Compared with our last survey in 2016, their overall prevalence in HMGs hasn’t changed significantly. Whether this will be different in the future with our aging population will be interesting to follow.

Published biannually, the SoHM report provides insight into these and other market-based dynamics that shape hospital medicine. The demand for hospital-based clinicians and the demands of acute inpatient care are leading to the broad and inclusive nature of hospital medicine. Our staffing will continue to be met not only by internal medicine and family medicine physicians but also through these other specialties joining our ranks and adding diversity to our profession.

Dr. Sites is the executive medical director of acute medicine at Providence St. Joseph Health, Oregon, and a member of SHM’s Practice Analysis Committee. She leads the hospital medicine programs and is involved in strategy development and alignment of acute inpatient medicine services at eight member hospitals. She has been a practicing hospitalist for 20 years and volunteers on medical mission trips to Guatemala annually.

Our profession continues to experience steady growth, and demand for hospitalist physicians exceeds supply. In a recent article in The Hospitalist, Andrew White, MD, SFHM, highlighted the fact that most hospital medicine groups (HMGs) are constantly recruiting and open positions are not uncommon.

When we think about recruitment and staffing, I bet many of us think principally of physicians trained in the general medicine specialties of internal medicine, family medicine, and pediatrics. Yet, to help meet demand for hospital-based clinicians, HMGs sometimes turn to physicians certified in emergency medicine, critical care, geriatric medicine, palliative care, and other fields.

To gain a better understanding of the diversity within our profession, the Society of Hospital Medicine’s State of Hospital Medicine survey asked HMGs whether they employ at least one physician in these various specialties. Results published in the recently released 2018 State of Hospital Medicine (SoHM) Report show significant differences among groups, affected by location, group size, and type of employer.

At the core of our profession are physicians trained in internal medicine, present in 99.2% of adult medicine HMGs throughout the United States. No surprise given that our field was founded by internists and remains a popular career choice for IM residency graduates. Family physicians follow, with the highest percentage of groups employing at least one FP located in the southern United States at 70.3% and lowest in the west at 54.7%. Small-sized groups – fewer than 10 full-time equivalents (FTEs) – were also more likely to employ FPs.

This speaks to the challenge – often faced by smaller hospitals – of covering both adult and pediatric patient populations and limited workforce availability. Pediatrics- and internal medicine/pediatrics–trained physicians help meet this need and were prevalent within small-sized groups. Another distinction found in the report is that, while 92.1% of multistate hospitalist management companies employed family physicians, only 28.8% of academic university settings did so. Partly because of Accreditation Council for Graduate Medical Education requirements for IM-certified teaching attending for internal medicine residents, FP and other specialties are filling some non–teaching hospitalist positions within our academic programs.

What may be surprising is that emergency medicine and critical care had the largest increase in representation in hospital medicine. The two specialties showed similar growth trends, with a larger presence in the South and Midwest states and 56% of multistate hospitalist management companies employing them. Small- to medium-sized groups of up to 20 FTEs were also more likely to have physicians from these fields, with up to 44% of groups doing so. This is a significant change from 2016, when less than 3.4% of all HMGs overall had a physician certified in emergency or critical care medicine.

This finding seems to coincide with the growth in hospital medicine groups who are covering both ED and inpatient services. For small and rural hospitals, it has become necessary and beneficial to have physicians capable of covering both clinical settings.

Contrast this with geriatric medicine and palliative care. Here, we saw these two specialties to be present in our academic institutions at 26.8% and 22.5%, respectively. Large-sized HMGs were more likely to employ them, whereas their presence in multistate management groups or private multispecialty/primary care groups was quite low. Compared with our last survey in 2016, their overall prevalence in HMGs hasn’t changed significantly. Whether this will be different in the future with our aging population will be interesting to follow.

Published biannually, the SoHM report provides insight into these and other market-based dynamics that shape hospital medicine. The demand for hospital-based clinicians and the demands of acute inpatient care are leading to the broad and inclusive nature of hospital medicine. Our staffing will continue to be met not only by internal medicine and family medicine physicians but also through these other specialties joining our ranks and adding diversity to our profession.

Dr. Sites is the executive medical director of acute medicine at Providence St. Joseph Health, Oregon, and a member of SHM’s Practice Analysis Committee. She leads the hospital medicine programs and is involved in strategy development and alignment of acute inpatient medicine services at eight member hospitals. She has been a practicing hospitalist for 20 years and volunteers on medical mission trips to Guatemala annually.

The proportion of women speaking at medical conferences in the United States and Canada increased significantly between 2007 and 2017, while the proportion at surgical specialty conferences lagged noticeably behind, according to new research.

“Although female representation at academic meetings has been identified as an important gender equity issue, the proportion of conference speakers who are women has not yet been systematically measured across different medical subspecialties,” wrote Shannon M. Ruzycki, MD, and her colleagues from the University of Calgary (Alta.). The report is in JAMA Network Open.

Using the Web of Science Conference database, the investigators identified 181 conferences and 701 unique meetings (40 in 2007, 104 in 2013, 115 in 2014, 124 in 2015, 137 in 2016, and 181 in 2017). The list of names from each meeting program was analyzed by the Gender Balance Assessment Tool to identify the likely proportion of female speakers by assigning a probability of each name belonging to a gender, based on social media data.

In 2007, the proportion of female speakers was 24.6% , which increased to 34.1% by 2017, an average increase of 0.97% per year. The range of female speakers at each meeting ranged from 0% to 82.6%, with 82 (12%) of the 701 meetings having more than 50% female speakers. The proportion of female speakers was slightly less than the proportion of female doctors in the United States and Canada in 2007 (26.1%), but was slightly greater than the proportion of female doctors in 2015 (32.4%).

During the study period, the proportion of female speakers at surgical specialty conferences was significantly lower than that for medical specialty conferences (20.1% in 2007 and 28.4% in 2017 vs. 29.9% in 2007 and 38.8% in 2017). While the number of speakers at medical meetings in 2015 matched the proportion of doctors in the United States and Canada in that year, the proportion of speakers at surgical meetings was noticeably higher than the number of female surgeons.

“We hypothesize that the low proportion of female speakers at medical conferences reflects broader gender inequity within the medical profession, particularly in subspecialties where the majority of physicians are men. It has been shown that the presence of female role models in male-dominated career streams can increase engagement of young women,” the investigators wrote. “Exposure to female speakers at medical conferences may be a means of encouraging female medical students and residents to choose specialties that have historically been male dominated. Strategies to promote inclusivity of female speakers at academic conferences may therefore represent an important opportunity to influence gender equity within medicine,” they concluded.

The University of Calgary funded the study. The authors reported no conflicts of interest.

[email protected]

SOURCE: Ruzycki SM et al. JAMA Netw Open. 2019 Apr 12. doi: 10.1001/jamanetworkopen.2019.2103.

The proportion of women speaking at medical conferences in the United States and Canada increased significantly between 2007 and 2017, while the proportion at surgical specialty conferences lagged noticeably behind, according to new research.

“Although female representation at academic meetings has been identified as an important gender equity issue, the proportion of conference speakers who are women has not yet been systematically measured across different medical subspecialties,” wrote Shannon M. Ruzycki, MD, and her colleagues from the University of Calgary (Alta.). The report is in JAMA Network Open.

Using the Web of Science Conference database, the investigators identified 181 conferences and 701 unique meetings (40 in 2007, 104 in 2013, 115 in 2014, 124 in 2015, 137 in 2016, and 181 in 2017). The list of names from each meeting program was analyzed by the Gender Balance Assessment Tool to identify the likely proportion of female speakers by assigning a probability of each name belonging to a gender, based on social media data.

In 2007, the proportion of female speakers was 24.6% , which increased to 34.1% by 2017, an average increase of 0.97% per year. The range of female speakers at each meeting ranged from 0% to 82.6%, with 82 (12%) of the 701 meetings having more than 50% female speakers. The proportion of female speakers was slightly less than the proportion of female doctors in the United States and Canada in 2007 (26.1%), but was slightly greater than the proportion of female doctors in 2015 (32.4%).

During the study period, the proportion of female speakers at surgical specialty conferences was significantly lower than that for medical specialty conferences (20.1% in 2007 and 28.4% in 2017 vs. 29.9% in 2007 and 38.8% in 2017). While the number of speakers at medical meetings in 2015 matched the proportion of doctors in the United States and Canada in that year, the proportion of speakers at surgical meetings was noticeably higher than the number of female surgeons.

“We hypothesize that the low proportion of female speakers at medical conferences reflects broader gender inequity within the medical profession, particularly in subspecialties where the majority of physicians are men. It has been shown that the presence of female role models in male-dominated career streams can increase engagement of young women,” the investigators wrote. “Exposure to female speakers at medical conferences may be a means of encouraging female medical students and residents to choose specialties that have historically been male dominated. Strategies to promote inclusivity of female speakers at academic conferences may therefore represent an important opportunity to influence gender equity within medicine,” they concluded.

The University of Calgary funded the study. The authors reported no conflicts of interest.

[email protected]

SOURCE: Ruzycki SM et al. JAMA Netw Open. 2019 Apr 12. doi: 10.1001/jamanetworkopen.2019.2103.

The proportion of women speaking at medical conferences in the United States and Canada increased significantly between 2007 and 2017, while the proportion at surgical specialty conferences lagged noticeably behind, according to new research.

“Although female representation at academic meetings has been identified as an important gender equity issue, the proportion of conference speakers who are women has not yet been systematically measured across different medical subspecialties,” wrote Shannon M. Ruzycki, MD, and her colleagues from the University of Calgary (Alta.). The report is in JAMA Network Open.

Using the Web of Science Conference database, the investigators identified 181 conferences and 701 unique meetings (40 in 2007, 104 in 2013, 115 in 2014, 124 in 2015, 137 in 2016, and 181 in 2017). The list of names from each meeting program was analyzed by the Gender Balance Assessment Tool to identify the likely proportion of female speakers by assigning a probability of each name belonging to a gender, based on social media data.

In 2007, the proportion of female speakers was 24.6% , which increased to 34.1% by 2017, an average increase of 0.97% per year. The range of female speakers at each meeting ranged from 0% to 82.6%, with 82 (12%) of the 701 meetings having more than 50% female speakers. The proportion of female speakers was slightly less than the proportion of female doctors in the United States and Canada in 2007 (26.1%), but was slightly greater than the proportion of female doctors in 2015 (32.4%).

During the study period, the proportion of female speakers at surgical specialty conferences was significantly lower than that for medical specialty conferences (20.1% in 2007 and 28.4% in 2017 vs. 29.9% in 2007 and 38.8% in 2017). While the number of speakers at medical meetings in 2015 matched the proportion of doctors in the United States and Canada in that year, the proportion of speakers at surgical meetings was noticeably higher than the number of female surgeons.

“We hypothesize that the low proportion of female speakers at medical conferences reflects broader gender inequity within the medical profession, particularly in subspecialties where the majority of physicians are men. It has been shown that the presence of female role models in male-dominated career streams can increase engagement of young women,” the investigators wrote. “Exposure to female speakers at medical conferences may be a means of encouraging female medical students and residents to choose specialties that have historically been male dominated. Strategies to promote inclusivity of female speakers at academic conferences may therefore represent an important opportunity to influence gender equity within medicine,” they concluded.

The University of Calgary funded the study. The authors reported no conflicts of interest.

[email protected]

SOURCE: Ruzycki SM et al. JAMA Netw Open. 2019 Apr 12. doi: 10.1001/jamanetworkopen.2019.2103.

Clinical question: Is an oral direct factor Xa inhibitor an effective alternative to low-molecular-weight heparin (LMWH) in treating cancer related venous thromboembolism (VTE)?

Background: LMWH has been the standard of care for treatment in patients with VTE and cancer. A newer class of drug, the direct factor Xa inhibitors, have been shown to be noninferior to vitamin K antagonists (VKAs) in treatment of VTE in noncancer patients, but little is known about their use in patients with cancer.

Study Design: Randomized, open-label, multicenter pilot trial.

Setting: United Kingdom; patients were recruited through the Clinical Trials Unit at the University of Warwick, Coventry.

Synopsis: The authors randomly assigned 406 cancer patients with diagnosed VTE either to the LMWH group or to the oral direct factor Xa inhibitor group to evaluate the primary endpoint of VTE reoccurrence and secondary endpoints of major bleeding or clinically relevant but not major bleeding (CRNMB). Rivaroxaban was noninferior to dalteparin in preventing VTE reoccurrence, with a 6-month VTE reoccurrence rate for dalteparin of 11% (95% confidence interval, 7%-16%) and a reoccurrence rate of 6% for rivaroxaban (95% CI, 2%-9%). Rates of major bleeding events were similar, although patients with esophageal or gastroesophageal cancers tended to experience more major bleeds with rivaroxaban than with dalteparin (4 of 11 vs. 1 of 19). CRNMB was 4% for dalteparin and 13% for rivaroxaban (hazard ratio, 3.76; 95% CI, 1.64-8.69). Limitations include slow recruitment, high mortality rate, and the treatment length being only 6 months.

Bottom line: In this small study, rivaroxaban was equally effective at reducing the rate of reoccurrence of cancer related VTE at 6 months but had higher rates of CRNMB. Patients with GI cancers may be at higher risk for major GI bleeding with rivaroxaban.

Citation: Young AM et al. Comparison of an oral factor Xa inhibitor with low molecular weight heparin in patients with cancer with venous thromboembolism: Results of a randomized trial (SELECT-D). J Clin Oncol. 2018 Jul 10. 36(20):2017-23.

Dr. Marten is an assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

Clinical question: Is an oral direct factor Xa inhibitor an effective alternative to low-molecular-weight heparin (LMWH) in treating cancer related venous thromboembolism (VTE)?

Background: LMWH has been the standard of care for treatment in patients with VTE and cancer. A newer class of drug, the direct factor Xa inhibitors, have been shown to be noninferior to vitamin K antagonists (VKAs) in treatment of VTE in noncancer patients, but little is known about their use in patients with cancer.

Study Design: Randomized, open-label, multicenter pilot trial.

Setting: United Kingdom; patients were recruited through the Clinical Trials Unit at the University of Warwick, Coventry.

Synopsis: The authors randomly assigned 406 cancer patients with diagnosed VTE either to the LMWH group or to the oral direct factor Xa inhibitor group to evaluate the primary endpoint of VTE reoccurrence and secondary endpoints of major bleeding or clinically relevant but not major bleeding (CRNMB). Rivaroxaban was noninferior to dalteparin in preventing VTE reoccurrence, with a 6-month VTE reoccurrence rate for dalteparin of 11% (95% confidence interval, 7%-16%) and a reoccurrence rate of 6% for rivaroxaban (95% CI, 2%-9%). Rates of major bleeding events were similar, although patients with esophageal or gastroesophageal cancers tended to experience more major bleeds with rivaroxaban than with dalteparin (4 of 11 vs. 1 of 19). CRNMB was 4% for dalteparin and 13% for rivaroxaban (hazard ratio, 3.76; 95% CI, 1.64-8.69). Limitations include slow recruitment, high mortality rate, and the treatment length being only 6 months.

Bottom line: In this small study, rivaroxaban was equally effective at reducing the rate of reoccurrence of cancer related VTE at 6 months but had higher rates of CRNMB. Patients with GI cancers may be at higher risk for major GI bleeding with rivaroxaban.

Citation: Young AM et al. Comparison of an oral factor Xa inhibitor with low molecular weight heparin in patients with cancer with venous thromboembolism: Results of a randomized trial (SELECT-D). J Clin Oncol. 2018 Jul 10. 36(20):2017-23.

Dr. Marten is an assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

Clinical question: Is an oral direct factor Xa inhibitor an effective alternative to low-molecular-weight heparin (LMWH) in treating cancer related venous thromboembolism (VTE)?

Background: LMWH has been the standard of care for treatment in patients with VTE and cancer. A newer class of drug, the direct factor Xa inhibitors, have been shown to be noninferior to vitamin K antagonists (VKAs) in treatment of VTE in noncancer patients, but little is known about their use in patients with cancer.

Study Design: Randomized, open-label, multicenter pilot trial.

Setting: United Kingdom; patients were recruited through the Clinical Trials Unit at the University of Warwick, Coventry.

Synopsis: The authors randomly assigned 406 cancer patients with diagnosed VTE either to the LMWH group or to the oral direct factor Xa inhibitor group to evaluate the primary endpoint of VTE reoccurrence and secondary endpoints of major bleeding or clinically relevant but not major bleeding (CRNMB). Rivaroxaban was noninferior to dalteparin in preventing VTE reoccurrence, with a 6-month VTE reoccurrence rate for dalteparin of 11% (95% confidence interval, 7%-16%) and a reoccurrence rate of 6% for rivaroxaban (95% CI, 2%-9%). Rates of major bleeding events were similar, although patients with esophageal or gastroesophageal cancers tended to experience more major bleeds with rivaroxaban than with dalteparin (4 of 11 vs. 1 of 19). CRNMB was 4% for dalteparin and 13% for rivaroxaban (hazard ratio, 3.76; 95% CI, 1.64-8.69). Limitations include slow recruitment, high mortality rate, and the treatment length being only 6 months.

Bottom line: In this small study, rivaroxaban was equally effective at reducing the rate of reoccurrence of cancer related VTE at 6 months but had higher rates of CRNMB. Patients with GI cancers may be at higher risk for major GI bleeding with rivaroxaban.

Citation: Young AM et al. Comparison of an oral factor Xa inhibitor with low molecular weight heparin in patients with cancer with venous thromboembolism: Results of a randomized trial (SELECT-D). J Clin Oncol. 2018 Jul 10. 36(20):2017-23.

Dr. Marten is an assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.

Clinical question: Does early renal replacement therapy (RRT) initiation affect clinical outcomes in patients with severe acute kidney injury (AKI) in the setting of septic shock or acute respiratory distress syndrome (ARDS)?

Background: Critically ill patients with AKI can benefit from RRT via improvement of electrolyte abnormalities, volume overload, and acid-base status. Potential harm from RRT includes complications of central venous access, intradialytic hypotension, and the bleeding risk of anticoagulation. The optimal timing of the elective initiation of RRT for AKI in septic shock or ARDS is unknown.

Study design: A post hoc subgroup study of a randomized, controlled trial.

Setting: Thirty-one ICUs in France.

Synopsis: Using data from the Artificial Kidney Initiation in Kidney Injury trial, the authors evaluated 619 patients with severe AKI and requirement for catecholamine infusion and/or invasive mechanical ventilation. Patients were randomly given RRT in an early or a delayed time frame. The early strategy involved RRT as soon as possible after randomization. In addition to the other parameters, the patients in the delayed group were given RRT for the following: anuria/oliguria 72 hours after randomization, blood urea nitrogen greater than 112 mg/dL, serum potassium greater than 6 mmol/L, metabolic acidosis with pH less than 7.15, or pulmonary edema from fluid overload causing severe hypoxia.

Early RRT did not show significant improvement in 60-day mortality, length of mechanical ventilation, or length of stay, compared with delayed RRT. The delayed RRT strategy was significantly associated with renal function recovery, with hazard ratios of 1.7 in ARDS (P = .009) and 1.9 in septic shock (P less than .001). Additionally, the likelihood of adequate urinary output was greater in the delayed RRT group.

Bottom line: A delayed RRT strategy in those with severe AKI and septic shock or ARDS may safely afford time for renal recovery in some patients.

Citation: Gaudry S et al. Timing of renal support and outcome of septic shock and acute respiratory distress syndrome. A post hoc analysis of the AKIKI randomized clinical trial. Am J Respir Crit Care Med. 2018;198(1):58-66.

Dr. James is a hospitalist at Emory University Hospital Midtown and an assistant professor at Emory University, both in Atlanta.

Clinical question: Does early renal replacement therapy (RRT) initiation affect clinical outcomes in patients with severe acute kidney injury (AKI) in the setting of septic shock or acute respiratory distress syndrome (ARDS)?

Background: Critically ill patients with AKI can benefit from RRT via improvement of electrolyte abnormalities, volume overload, and acid-base status. Potential harm from RRT includes complications of central venous access, intradialytic hypotension, and the bleeding risk of anticoagulation. The optimal timing of the elective initiation of RRT for AKI in septic shock or ARDS is unknown.

Study design: A post hoc subgroup study of a randomized, controlled trial.

Setting: Thirty-one ICUs in France.

Synopsis: Using data from the Artificial Kidney Initiation in Kidney Injury trial, the authors evaluated 619 patients with severe AKI and requirement for catecholamine infusion and/or invasive mechanical ventilation. Patients were randomly given RRT in an early or a delayed time frame. The early strategy involved RRT as soon as possible after randomization. In addition to the other parameters, the patients in the delayed group were given RRT for the following: anuria/oliguria 72 hours after randomization, blood urea nitrogen greater than 112 mg/dL, serum potassium greater than 6 mmol/L, metabolic acidosis with pH less than 7.15, or pulmonary edema from fluid overload causing severe hypoxia.

Early RRT did not show significant improvement in 60-day mortality, length of mechanical ventilation, or length of stay, compared with delayed RRT. The delayed RRT strategy was significantly associated with renal function recovery, with hazard ratios of 1.7 in ARDS (P = .009) and 1.9 in septic shock (P less than .001). Additionally, the likelihood of adequate urinary output was greater in the delayed RRT group.

Bottom line: A delayed RRT strategy in those with severe AKI and septic shock or ARDS may safely afford time for renal recovery in some patients.

Citation: Gaudry S et al. Timing of renal support and outcome of septic shock and acute respiratory distress syndrome. A post hoc analysis of the AKIKI randomized clinical trial. Am J Respir Crit Care Med. 2018;198(1):58-66.

Dr. James is a hospitalist at Emory University Hospital Midtown and an assistant professor at Emory University, both in Atlanta.

Clinical question: Does early renal replacement therapy (RRT) initiation affect clinical outcomes in patients with severe acute kidney injury (AKI) in the setting of septic shock or acute respiratory distress syndrome (ARDS)?

Background: Critically ill patients with AKI can benefit from RRT via improvement of electrolyte abnormalities, volume overload, and acid-base status. Potential harm from RRT includes complications of central venous access, intradialytic hypotension, and the bleeding risk of anticoagulation. The optimal timing of the elective initiation of RRT for AKI in septic shock or ARDS is unknown.

Study design: A post hoc subgroup study of a randomized, controlled trial.

Setting: Thirty-one ICUs in France.

Synopsis: Using data from the Artificial Kidney Initiation in Kidney Injury trial, the authors evaluated 619 patients with severe AKI and requirement for catecholamine infusion and/or invasive mechanical ventilation. Patients were randomly given RRT in an early or a delayed time frame. The early strategy involved RRT as soon as possible after randomization. In addition to the other parameters, the patients in the delayed group were given RRT for the following: anuria/oliguria 72 hours after randomization, blood urea nitrogen greater than 112 mg/dL, serum potassium greater than 6 mmol/L, metabolic acidosis with pH less than 7.15, or pulmonary edema from fluid overload causing severe hypoxia.

Early RRT did not show significant improvement in 60-day mortality, length of mechanical ventilation, or length of stay, compared with delayed RRT. The delayed RRT strategy was significantly associated with renal function recovery, with hazard ratios of 1.7 in ARDS (P = .009) and 1.9 in septic shock (P less than .001). Additionally, the likelihood of adequate urinary output was greater in the delayed RRT group.

Bottom line: A delayed RRT strategy in those with severe AKI and septic shock or ARDS may safely afford time for renal recovery in some patients.

Citation: Gaudry S et al. Timing of renal support and outcome of septic shock and acute respiratory distress syndrome. A post hoc analysis of the AKIKI randomized clinical trial. Am J Respir Crit Care Med. 2018;198(1):58-66.

Dr. James is a hospitalist at Emory University Hospital Midtown and an assistant professor at Emory University, both in Atlanta.

NEW ORLEANS – Mounting evidence shows that heart failure patient mortality increased as an unintended consequence of a Medicare program that penalizes hospitals with too many 30-day readmissions of heart failure patients. This has prompted discussions among cardiologists, Medicare officials, and other stakeholders in an attempt to modify the penalty program so it no longer considers just readmissions but instead bases penalties on broader and more nuanced measures of patient outcomes.

Mitchel L. Zoler/MDedge News

Staffers at the Centers for Medicare & Medicaid Services, the federal agency that manages Medicare, “said that they take this seriously and will look into it, and they are interested in next-generation measures that are more patient centered” than simply the 30-day readmission rate, Gregg C. Fonarow, MD, said in an interview at the annual meeting of the American College of Cardiology. “This is a case where there is credible evidence of increased mortality that is consistent, reproducible, and strongly associated with the penalty and cannot be otherwise explained,” said Dr. Fonarow, professor of medicine and cochief of cardiology at the University of California, Los Angeles.

He is among the most active researchers to document that, while CMS’s Hospital Readmissions Reduction Program (HRRP) led to significantly reduced readmission rates in patients with heart failure, this came at a cost of a significant increase in mortality among the same patients. For example, an article he published in 2018 that analyzed more than 115,000 Medicare beneficiaries during 2006-2014 showed that during the penalty phase, which began in 2012, readmissions fell after adjustment by a relative 8%, but adjusted mortality rose by a relative 10%, compared with how patients had fared prior to launching the HRRP (JAMA Cardiol. 2018 Jan;3[1]:44-53). Recent reports from other research groups have had similar findings, such as a study of more than 3 million Medicare beneficiaries with heart failure during 2005-2015 that also showed significantly increased mortality after the penalty phase for readmissions began (JAMA. 2018 Dec 25;320[24]:2542-52). In a commentary that accompanied this report, Dr. Fonarow cited the multiple analyses that show consistent findings and the need for CMS to “initiate an expeditious reconsideration and revision” of their current approach to penalizing hospitals for heart failure readmissions (JAMA. 2018 Dec 25;320[24]:2539-41).

The groups recently in discussion with CMS about this issue include the American College of Cardiology, the American Heart Association, the Heart Failure Society of America, the American College of Physicians, the American Hospital Association, and several other medical professional groups, said Biykem Bozkurt, MD, who has worked with Dr. Fonarow and representatives from these organizations in talks with CMS.

“We are trying to find a harmonized approach with patient-centric outcomes that reflect true improvements in quality of care,” she said in an interview. One possibility up for consideration is a combined measure of heart failure readmissions, mortality, and a patient-reported outcome. The measure would go to CMS directly from each patient’s electronic medical record, making data collection less burdensome to clinicians, said Dr. Bozkurt, professor of medicine at Baylor College of Medicine and cardiology section chief at the VA Medical Center in Houston. She expressed hope that a change in the CMS metric might happen later this year.

“CMS can’t simply stop the HRRP, so the discussion is on how to get a meaningful change. I’m increasingly optimistic, because the findings of harm [from current policies] are impossible to ignore,” Dr. Fonarow said. “There will be increasing pressure on CMS to develop a pathway to make modifications. It’s egregious to continue a policy that’s been associated with harm” to heart failure patients.

Dr. Fonarow and Dr. Bozkurt had no relevant commercial disclosures.

[email protected]

NEW ORLEANS – Mounting evidence shows that heart failure patient mortality increased as an unintended consequence of a Medicare program that penalizes hospitals with too many 30-day readmissions of heart failure patients. This has prompted discussions among cardiologists, Medicare officials, and other stakeholders in an attempt to modify the penalty program so it no longer considers just readmissions but instead bases penalties on broader and more nuanced measures of patient outcomes.

Mitchel L. Zoler/MDedge News

Staffers at the Centers for Medicare & Medicaid Services, the federal agency that manages Medicare, “said that they take this seriously and will look into it, and they are interested in next-generation measures that are more patient centered” than simply the 30-day readmission rate, Gregg C. Fonarow, MD, said in an interview at the annual meeting of the American College of Cardiology. “This is a case where there is credible evidence of increased mortality that is consistent, reproducible, and strongly associated with the penalty and cannot be otherwise explained,” said Dr. Fonarow, professor of medicine and cochief of cardiology at the University of California, Los Angeles.

He is among the most active researchers to document that, while CMS’s Hospital Readmissions Reduction Program (HRRP) led to significantly reduced readmission rates in patients with heart failure, this came at a cost of a significant increase in mortality among the same patients. For example, an article he published in 2018 that analyzed more than 115,000 Medicare beneficiaries during 2006-2014 showed that during the penalty phase, which began in 2012, readmissions fell after adjustment by a relative 8%, but adjusted mortality rose by a relative 10%, compared with how patients had fared prior to launching the HRRP (JAMA Cardiol. 2018 Jan;3[1]:44-53). Recent reports from other research groups have had similar findings, such as a study of more than 3 million Medicare beneficiaries with heart failure during 2005-2015 that also showed significantly increased mortality after the penalty phase for readmissions began (JAMA. 2018 Dec 25;320[24]:2542-52). In a commentary that accompanied this report, Dr. Fonarow cited the multiple analyses that show consistent findings and the need for CMS to “initiate an expeditious reconsideration and revision” of their current approach to penalizing hospitals for heart failure readmissions (JAMA. 2018 Dec 25;320[24]:2539-41).

The groups recently in discussion with CMS about this issue include the American College of Cardiology, the American Heart Association, the Heart Failure Society of America, the American College of Physicians, the American Hospital Association, and several other medical professional groups, said Biykem Bozkurt, MD, who has worked with Dr. Fonarow and representatives from these organizations in talks with CMS.

“We are trying to find a harmonized approach with patient-centric outcomes that reflect true improvements in quality of care,” she said in an interview. One possibility up for consideration is a combined measure of heart failure readmissions, mortality, and a patient-reported outcome. The measure would go to CMS directly from each patient’s electronic medical record, making data collection less burdensome to clinicians, said Dr. Bozkurt, professor of medicine at Baylor College of Medicine and cardiology section chief at the VA Medical Center in Houston. She expressed hope that a change in the CMS metric might happen later this year.

“CMS can’t simply stop the HRRP, so the discussion is on how to get a meaningful change. I’m increasingly optimistic, because the findings of harm [from current policies] are impossible to ignore,” Dr. Fonarow said. “There will be increasing pressure on CMS to develop a pathway to make modifications. It’s egregious to continue a policy that’s been associated with harm” to heart failure patients.

Dr. Fonarow and Dr. Bozkurt had no relevant commercial disclosures.

[email protected]

NEW ORLEANS – Mounting evidence shows that heart failure patient mortality increased as an unintended consequence of a Medicare program that penalizes hospitals with too many 30-day readmissions of heart failure patients. This has prompted discussions among cardiologists, Medicare officials, and other stakeholders in an attempt to modify the penalty program so it no longer considers just readmissions but instead bases penalties on broader and more nuanced measures of patient outcomes.

Mitchel L. Zoler/MDedge News

Staffers at the Centers for Medicare & Medicaid Services, the federal agency that manages Medicare, “said that they take this seriously and will look into it, and they are interested in next-generation measures that are more patient centered” than simply the 30-day readmission rate, Gregg C. Fonarow, MD, said in an interview at the annual meeting of the American College of Cardiology. “This is a case where there is credible evidence of increased mortality that is consistent, reproducible, and strongly associated with the penalty and cannot be otherwise explained,” said Dr. Fonarow, professor of medicine and cochief of cardiology at the University of California, Los Angeles.

He is among the most active researchers to document that, while CMS’s Hospital Readmissions Reduction Program (HRRP) led to significantly reduced readmission rates in patients with heart failure, this came at a cost of a significant increase in mortality among the same patients. For example, an article he published in 2018 that analyzed more than 115,000 Medicare beneficiaries during 2006-2014 showed that during the penalty phase, which began in 2012, readmissions fell after adjustment by a relative 8%, but adjusted mortality rose by a relative 10%, compared with how patients had fared prior to launching the HRRP (JAMA Cardiol. 2018 Jan;3[1]:44-53). Recent reports from other research groups have had similar findings, such as a study of more than 3 million Medicare beneficiaries with heart failure during 2005-2015 that also showed significantly increased mortality after the penalty phase for readmissions began (JAMA. 2018 Dec 25;320[24]:2542-52). In a commentary that accompanied this report, Dr. Fonarow cited the multiple analyses that show consistent findings and the need for CMS to “initiate an expeditious reconsideration and revision” of their current approach to penalizing hospitals for heart failure readmissions (JAMA. 2018 Dec 25;320[24]:2539-41).

The groups recently in discussion with CMS about this issue include the American College of Cardiology, the American Heart Association, the Heart Failure Society of America, the American College of Physicians, the American Hospital Association, and several other medical professional groups, said Biykem Bozkurt, MD, who has worked with Dr. Fonarow and representatives from these organizations in talks with CMS.

“We are trying to find a harmonized approach with patient-centric outcomes that reflect true improvements in quality of care,” she said in an interview. One possibility up for consideration is a combined measure of heart failure readmissions, mortality, and a patient-reported outcome. The measure would go to CMS directly from each patient’s electronic medical record, making data collection less burdensome to clinicians, said Dr. Bozkurt, professor of medicine at Baylor College of Medicine and cardiology section chief at the VA Medical Center in Houston. She expressed hope that a change in the CMS metric might happen later this year.

“CMS can’t simply stop the HRRP, so the discussion is on how to get a meaningful change. I’m increasingly optimistic, because the findings of harm [from current policies] are impossible to ignore,” Dr. Fonarow said. “There will be increasing pressure on CMS to develop a pathway to make modifications. It’s egregious to continue a policy that’s been associated with harm” to heart failure patients.

Dr. Fonarow and Dr. Bozkurt had no relevant commercial disclosures.

[email protected]

The Food and Drug Administration is making changes to opioid analgesic labeling to give better information to clinicians on how to properly taper patients dependent on opioid use, according to Douglas Throckmorton, MD, deputy director for regulatory programs in the FDA’s Center for Drug Evaluation and Research.

Wikimedia Commons/FitzColinGerald/Creative Commons License

The FDA has recently received reports that patients physically dependent on opioid pain medicines who are taken off their medication too quickly have experienced serious adverse events, such as withdrawal symptoms, uncontrolled pain, and suicide. Both the FDA and the Centers for Disease Control and Prevention offer guidelines on how to properly taper opioids, Dr. Throckmorton said, but more needs to be done to ensure that patients are being provided with the correct advice and care.

The changes to the labels will include expanded information to health care clinicians and are intended to be used when both the clinician and patient have agreed to reduce the opioid dosage. When this is discussed, factors that should be considered include the dose of the drug, the duration of treatment, the type of pain being treated, and the physical and psychological attributes of the patient.

Other actions the FDA is pursuing to combat opioid use disorder include working with the National Academies of Sciences, Engineering, and Medicine on guidelines for the proper opioid analgesic prescribing for acute pain resulting from specific conditions or procedures, and advancing policies that make immediate-release opioid formulations available in fixed-quantity packaging for 1 or 2 days.

“The FDA remains committed to addressing the opioid crisis on all fronts, with a significant focus on decreasing unnecessary exposure to opioids and preventing new addiction; supporting the treatment of those with opioid use disorder; fostering the development of novel pain treatment therapies and opioids more resistant to abuse and misuse; and taking action against those involved in the illegal importation and sale of opioids,” Dr. Throckmorton said.

Find the full statement by Dr. Throckmorton on the FDA website.

[email protected]

The Food and Drug Administration is making changes to opioid analgesic labeling to give better information to clinicians on how to properly taper patients dependent on opioid use, according to Douglas Throckmorton, MD, deputy director for regulatory programs in the FDA’s Center for Drug Evaluation and Research.

Wikimedia Commons/FitzColinGerald/Creative Commons License

The FDA has recently received reports that patients physically dependent on opioid pain medicines who are taken off their medication too quickly have experienced serious adverse events, such as withdrawal symptoms, uncontrolled pain, and suicide. Both the FDA and the Centers for Disease Control and Prevention offer guidelines on how to properly taper opioids, Dr. Throckmorton said, but more needs to be done to ensure that patients are being provided with the correct advice and care.

The changes to the labels will include expanded information to health care clinicians and are intended to be used when both the clinician and patient have agreed to reduce the opioid dosage. When this is discussed, factors that should be considered include the dose of the drug, the duration of treatment, the type of pain being treated, and the physical and psychological attributes of the patient.

Other actions the FDA is pursuing to combat opioid use disorder include working with the National Academies of Sciences, Engineering, and Medicine on guidelines for the proper opioid analgesic prescribing for acute pain resulting from specific conditions or procedures, and advancing policies that make immediate-release opioid formulations available in fixed-quantity packaging for 1 or 2 days.

“The FDA remains committed to addressing the opioid crisis on all fronts, with a significant focus on decreasing unnecessary exposure to opioids and preventing new addiction; supporting the treatment of those with opioid use disorder; fostering the development of novel pain treatment therapies and opioids more resistant to abuse and misuse; and taking action against those involved in the illegal importation and sale of opioids,” Dr. Throckmorton said.

Find the full statement by Dr. Throckmorton on the FDA website.

[email protected]

The Food and Drug Administration is making changes to opioid analgesic labeling to give better information to clinicians on how to properly taper patients dependent on opioid use, according to Douglas Throckmorton, MD, deputy director for regulatory programs in the FDA’s Center for Drug Evaluation and Research.

Wikimedia Commons/FitzColinGerald/Creative Commons License

The FDA has recently received reports that patients physically dependent on opioid pain medicines who are taken off their medication too quickly have experienced serious adverse events, such as withdrawal symptoms, uncontrolled pain, and suicide. Both the FDA and the Centers for Disease Control and Prevention offer guidelines on how to properly taper opioids, Dr. Throckmorton said, but more needs to be done to ensure that patients are being provided with the correct advice and care.

The changes to the labels will include expanded information to health care clinicians and are intended to be used when both the clinician and patient have agreed to reduce the opioid dosage. When this is discussed, factors that should be considered include the dose of the drug, the duration of treatment, the type of pain being treated, and the physical and psychological attributes of the patient.

Other actions the FDA is pursuing to combat opioid use disorder include working with the National Academies of Sciences, Engineering, and Medicine on guidelines for the proper opioid analgesic prescribing for acute pain resulting from specific conditions or procedures, and advancing policies that make immediate-release opioid formulations available in fixed-quantity packaging for 1 or 2 days.

“The FDA remains committed to addressing the opioid crisis on all fronts, with a significant focus on decreasing unnecessary exposure to opioids and preventing new addiction; supporting the treatment of those with opioid use disorder; fostering the development of novel pain treatment therapies and opioids more resistant to abuse and misuse; and taking action against those involved in the illegal importation and sale of opioids,” Dr. Throckmorton said.

Find the full statement by Dr. Throckmorton on the FDA website.

[email protected]

Clinical question: Does sodium bicarbonate treatment improve clinical outcomes in critically ill patients with severe metabolic acidosis?

Background: Severe acidemia is associated with impaired cardiac function, decreased perfusion, and increased mortality. Many physicians use sodium bicarbonate to improve hemodynamic stability in critically ill patients with acidemia. However, the use of sodium bicarbonate in this role remains controversial because the evidence to support it is limited.

Study design: Multicenter, open-label, randomized, controlled trial.

Setting: Twenty-six ICUs in France.

Synopsis: Investigators randomized 389 adult patients with severe acidemia and Sequential Organ Failure Assessment (SOFA) scores of 4 or greater or serum lactate level of 2 mmol/L or greater to receive either no sodium bicarbonate or 4.2% intravenous sodium bicarbonate. The primary composite outcome was at least organ failure at day 7 or mortality by day 28.

When compared as a whole, the treatment group did not demonstrate improvement in the primary outcome. However, patients with Acute Kidney Injury Network scores of 2 or 3 at enrollment who received bicarbonate had lower rates of the composite primary outcome (70% vs. 82%; P = .462). Additionally, 35% of the treatment group utilized a renal replacement therapy (RRT) during their ICU stay versus 52% of the control group (P = .0009).

Limitations of the study included unblinding of the ICU physicians and the lack of a control intravenous solution. Notably, 47 of the 194 patients in the control group received sodium bicarbonate as salvage therapy.

Bottom line: Sodium bicarbonate treatment may decrease the need for RRT in patients with significant metabolic acidemia and may decrease the likelihood of death or organ failure in those with severe acute kidney injury.

Citation: Jaber S et al. Sodium bicarbonate therapy for patients with severe metabolic acidaemia in the intensive care unit (BICAR-ICU): A multicentre, open-label, randomised controlled, phase 3 trial. Lancet. 2018;392(10141):31-40.

Dr. James is a hospitalist at Emory University Hospital Midtown and an assistant professor at Emory University, both in Atlanta

Clinical question: Does sodium bicarbonate treatment improve clinical outcomes in critically ill patients with severe metabolic acidosis?

Background: Severe acidemia is associated with impaired cardiac function, decreased perfusion, and increased mortality. Many physicians use sodium bicarbonate to improve hemodynamic stability in critically ill patients with acidemia. However, the use of sodium bicarbonate in this role remains controversial because the evidence to support it is limited.

Study design: Multicenter, open-label, randomized, controlled trial.

Setting: Twenty-six ICUs in France.

Synopsis: Investigators randomized 389 adult patients with severe acidemia and Sequential Organ Failure Assessment (SOFA) scores of 4 or greater or serum lactate level of 2 mmol/L or greater to receive either no sodium bicarbonate or 4.2% intravenous sodium bicarbonate. The primary composite outcome was at least organ failure at day 7 or mortality by day 28.

When compared as a whole, the treatment group did not demonstrate improvement in the primary outcome. However, patients with Acute Kidney Injury Network scores of 2 or 3 at enrollment who received bicarbonate had lower rates of the composite primary outcome (70% vs. 82%; P = .462). Additionally, 35% of the treatment group utilized a renal replacement therapy (RRT) during their ICU stay versus 52% of the control group (P = .0009).

Limitations of the study included unblinding of the ICU physicians and the lack of a control intravenous solution. Notably, 47 of the 194 patients in the control group received sodium bicarbonate as salvage therapy.

Bottom line: Sodium bicarbonate treatment may decrease the need for RRT in patients with significant metabolic acidemia and may decrease the likelihood of death or organ failure in those with severe acute kidney injury.

Citation: Jaber S et al. Sodium bicarbonate therapy for patients with severe metabolic acidaemia in the intensive care unit (BICAR-ICU): A multicentre, open-label, randomised controlled, phase 3 trial. Lancet. 2018;392(10141):31-40.

Dr. James is a hospitalist at Emory University Hospital Midtown and an assistant professor at Emory University, both in Atlanta

Clinical question: Does sodium bicarbonate treatment improve clinical outcomes in critically ill patients with severe metabolic acidosis?

Background: Severe acidemia is associated with impaired cardiac function, decreased perfusion, and increased mortality. Many physicians use sodium bicarbonate to improve hemodynamic stability in critically ill patients with acidemia. However, the use of sodium bicarbonate in this role remains controversial because the evidence to support it is limited.

Study design: Multicenter, open-label, randomized, controlled trial.

Setting: Twenty-six ICUs in France.

Synopsis: Investigators randomized 389 adult patients with severe acidemia and Sequential Organ Failure Assessment (SOFA) scores of 4 or greater or serum lactate level of 2 mmol/L or greater to receive either no sodium bicarbonate or 4.2% intravenous sodium bicarbonate. The primary composite outcome was at least organ failure at day 7 or mortality by day 28.

When compared as a whole, the treatment group did not demonstrate improvement in the primary outcome. However, patients with Acute Kidney Injury Network scores of 2 or 3 at enrollment who received bicarbonate had lower rates of the composite primary outcome (70% vs. 82%; P = .462). Additionally, 35% of the treatment group utilized a renal replacement therapy (RRT) during their ICU stay versus 52% of the control group (P = .0009).

Limitations of the study included unblinding of the ICU physicians and the lack of a control intravenous solution. Notably, 47 of the 194 patients in the control group received sodium bicarbonate as salvage therapy.

Bottom line: Sodium bicarbonate treatment may decrease the need for RRT in patients with significant metabolic acidemia and may decrease the likelihood of death or organ failure in those with severe acute kidney injury.

Citation: Jaber S et al. Sodium bicarbonate therapy for patients with severe metabolic acidaemia in the intensive care unit (BICAR-ICU): A multicentre, open-label, randomised controlled, phase 3 trial. Lancet. 2018;392(10141):31-40.

Dr. James is a hospitalist at Emory University Hospital Midtown and an assistant professor at Emory University, both in Atlanta

Presenter

Erin Shaughnessy, MD, MSHCM

Session title

Reaching Across the Aisle: Pediatric Co-Management with Surgery and Subspecialists

Session summary

Dr. Shaughnessy articulated a balanced approach to the importance of careful selection of patients needing to be co-managed by pediatric hospitalists. She compared two personal and very different experiences.

She initially managed a well-developed surgical co-management service at a quaternary, academic, free-standing children’s hospital, in which surgeons and subspecialists also admitted and managed patients to their own services. Currently, Dr. Shaughnessy is a division chief at Phoenix Children’s Hospital, a free-standing children’s hospital with a community hospital background, in which hospitalists admit most, if not all the patients, while subspecialty services have been transitioning only recently to having their own admitting services and employing the ideas of limited co-management.

She reminded the HM19 audience of the essential principles of co-management: shared responsibility, authority and accountability for the care of a hospitalized patient, discussing the scenarios, both from literature and real life, in which the line could become blurry at times.

Many pediatric programs are moving away from a traditional consultation model, Dr. Shaughnessy said, in which a consult is called for a new or a persistent problem with a patient, and where a consulting team signs off upon the resolved issue.

The more modern co-management model infuses a need for anticipatory and prevention-heavy approach, intertwined with fiscally responsible ideas that must be palatable for all: administration, hospitalists, and patients.

Dr. Shaughnessy reviewed a number of articles from both adult and pediatric literature with varied results, some that have shown decreased length of stay, decreased number of medical complications, decreased readmissions, decreased number of tests, but some that have also shown an increase in median hospital costs, emphasizing perhaps the importance of context in which one practices.

Finally, she identified patient selection, collaborative relationships, clear roles delineation, and excellence in communication as four main factors deciding the faith of a co-management model.
 

Key takeaways for HM

1. Careful selection of patients to be co-managed is essential and can prevent potential increase in costs and negative outcomes.

2. Success in medical and surgical co-management relies on well-delineated roles, collaborative culture, and immaculate communication.
 

Dr. Giordano is a pediatric neurosurgery hospitalist and assistant professor in pediatrics at Columbia University Irving Medical Center in New York.

Presenter

Erin Shaughnessy, MD, MSHCM

Session title

Reaching Across the Aisle: Pediatric Co-Management with Surgery and Subspecialists

Session summary

Dr. Shaughnessy articulated a balanced approach to the importance of careful selection of patients needing to be co-managed by pediatric hospitalists. She compared two personal and very different experiences.

She initially managed a well-developed surgical co-management service at a quaternary, academic, free-standing children’s hospital, in which surgeons and subspecialists also admitted and managed patients to their own services. Currently, Dr. Shaughnessy is a division chief at Phoenix Children’s Hospital, a free-standing children’s hospital with a community hospital background, in which hospitalists admit most, if not all the patients, while subspecialty services have been transitioning only recently to having their own admitting services and employing the ideas of limited co-management.

She reminded the HM19 audience of the essential principles of co-management: shared responsibility, authority and accountability for the care of a hospitalized patient, discussing the scenarios, both from literature and real life, in which the line could become blurry at times.

Many pediatric programs are moving away from a traditional consultation model, Dr. Shaughnessy said, in which a consult is called for a new or a persistent problem with a patient, and where a consulting team signs off upon the resolved issue.

The more modern co-management model infuses a need for anticipatory and prevention-heavy approach, intertwined with fiscally responsible ideas that must be palatable for all: administration, hospitalists, and patients.

Dr. Shaughnessy reviewed a number of articles from both adult and pediatric literature with varied results, some that have shown decreased length of stay, decreased number of medical complications, decreased readmissions, decreased number of tests, but some that have also shown an increase in median hospital costs, emphasizing perhaps the importance of context in which one practices.

Finally, she identified patient selection, collaborative relationships, clear roles delineation, and excellence in communication as four main factors deciding the faith of a co-management model.
 

Key takeaways for HM

1. Careful selection of patients to be co-managed is essential and can prevent potential increase in costs and negative outcomes.

2. Success in medical and surgical co-management relies on well-delineated roles, collaborative culture, and immaculate communication.
 

Dr. Giordano is a pediatric neurosurgery hospitalist and assistant professor in pediatrics at Columbia University Irving Medical Center in New York.

Presenter

Erin Shaughnessy, MD, MSHCM

Session title

Reaching Across the Aisle: Pediatric Co-Management with Surgery and Subspecialists

Session summary

Dr. Shaughnessy articulated a balanced approach to the importance of careful selection of patients needing to be co-managed by pediatric hospitalists. She compared two personal and very different experiences.

She initially managed a well-developed surgical co-management service at a quaternary, academic, free-standing children’s hospital, in which surgeons and subspecialists also admitted and managed patients to their own services. Currently, Dr. Shaughnessy is a division chief at Phoenix Children’s Hospital, a free-standing children’s hospital with a community hospital background, in which hospitalists admit most, if not all the patients, while subspecialty services have been transitioning only recently to having their own admitting services and employing the ideas of limited co-management.

She reminded the HM19 audience of the essential principles of co-management: shared responsibility, authority and accountability for the care of a hospitalized patient, discussing the scenarios, both from literature and real life, in which the line could become blurry at times.

Many pediatric programs are moving away from a traditional consultation model, Dr. Shaughnessy said, in which a consult is called for a new or a persistent problem with a patient, and where a consulting team signs off upon the resolved issue.

The more modern co-management model infuses a need for anticipatory and prevention-heavy approach, intertwined with fiscally responsible ideas that must be palatable for all: administration, hospitalists, and patients.

Dr. Shaughnessy reviewed a number of articles from both adult and pediatric literature with varied results, some that have shown decreased length of stay, decreased number of medical complications, decreased readmissions, decreased number of tests, but some that have also shown an increase in median hospital costs, emphasizing perhaps the importance of context in which one practices.

Finally, she identified patient selection, collaborative relationships, clear roles delineation, and excellence in communication as four main factors deciding the faith of a co-management model.
 

Key takeaways for HM

1. Careful selection of patients to be co-managed is essential and can prevent potential increase in costs and negative outcomes.

2. Success in medical and surgical co-management relies on well-delineated roles, collaborative culture, and immaculate communication.
 

Dr. Giordano is a pediatric neurosurgery hospitalist and assistant professor in pediatrics at Columbia University Irving Medical Center in New York.

U.S. spending on health care is growing rapidly and expected to reach 19.7% of gross domestic product by 2026.¹ In response, the Centers for Medicare and Medicaid Services and national organizations such as the American Board of Internal Medicine (ABIM) and the American College of Physicians (ACP) have launched initiatives to ensure that the value being delivered to patients is on par with the escalating cost of care.

Over the past 10 years, I have led and advised hundreds of small- and large-scale projects that focused on improving patient care quality and cost. Below, I share what I, along with other leaders in high-value care, have observed that it takes to implement successful and lasting improvements – for the benefit of patients and hospitals.
 

A brief history of high-value care

When compared to other wealthy countries, the United States spends disproportionately more money on health care. In 2016, U.S. health care spending was $3.3 trillion¹, or $10,348 per person.² Hospital care alone was responsible for a third of health spending and amounted to $1.1 trillion in 2016¹. By 2026, national health spending is projected to reach $5.7 trillion¹.

In response to escalating health care costs, CMS and other payers have shifted toward value-based reimbursements that tie payments to health care facilities and clinicians to their performance on selected quality, cost, and efficiency measures. For example, under the CMS Merit-based Incentive Payment System (MIPS), 5% of clinicians’ revenue in 2020 is tied to their 2018 performance in four categories: Quality, Cost, Improvement Activities, and Promoting Interoperability. The percentage of revenue at risk will increase to 9% in 2022, based on 2020 performance.

Rising health care costs put a burden not just on the federal and state budgets, but on individual and family budgets as well. Out-of-pocket spending grew 3.9% in 2016 to $352.5 billion¹ and is expected to increase in the future. High health care costs rightfully bring into question the value individual consumers of health care services are getting in return. If value is defined as the level of benefit achieved for a given cost, what is high-value care? The 2013 Institute of Medicine report³ defined high-value care as “the best care for the patient, with the optimal result for the circumstances, delivered at the right price.” It goes beyond a set of quality and cost measures used by payers to affect provider reimbursement and is driven by day-to-day individual providers’ decisions that affect individual patients’ outcomes and their cost of care.

High-value care has been embraced by national organizations. In 2012, the ABIM Foundation launched the Choosing Wisely initiative to support and promote conversations between clinicians and patients in choosing care that is truly necessary, supported by evidence, and free from harm. The result was an evidence-based list of recommendations from 540 specialty societies, including the Society of Hospital Medicine. The SHM – Adult Hospital Medicine list⁴ features the following “Five things physicians and patients should question”:

• Don’t place, or leave in place, urinary catheters for incontinence or convenience or monitoring of output for non–critically ill patients.
• Don’t prescribe medications for stress ulcer prophylaxis to medical inpatients unless at high risk for GI complications.
• Avoid transfusions of red blood cells for arbitrary hemoglobin or hematocrit thresholds and in the absence of symptoms of active coronary disease, heart failure, or stroke.
• Don’t order continuous telemetry monitoring outside of the ICU without using a protocol that governs continuation.
• Don’t perform repetitive CBC and chemistry testing in the face of clinical and lab stability.

The ACP launched a high-value care initiative that offers learning resources for clinicians and medical educators, clinical guidelines, and best practice advice. In 2012, a workgroup of internists convened by ACP developed a list of 37 clinical situations in which medical tests are commonly used but do not provide high value.⁵ Seven of those situations are applicable to adult hospital medicine.
 

High-value care today: What the experts say

More than 5 years later, what progress have hospitalists made in adopting high-value care practices? To answer this and other questions, I reached out to three national experts in high-value care in hospital medicine: Amit Pahwa, MD, assistant professor of medicine and pediatrics at Johns Hopkins University, Baltimore, and a course director of “Topics in interdisciplinary medicine: High-value health care”; Christopher Petrilli, MD, clinical assistant professor in the department of medicine at New York University Langone Health and clinical lead, Manhattan campus, value-based management; and Charlie Wray, DO, MS, assistant professor of medicine at the University of California in San Francisco and a coauthor of an article on high-value care in hospital medicine published recently in the Journal of General Internal Medicine^6.

The experts agree that awareness of high-value care among practicing physicians and medical trainees has increased in the last few years. Major professional publications have highlighted the topic, including The Journal of Hospital Medicine’s “Things We Do For No Reason” series, JAMA’s “Teachable Moments,” and the American Journal of Medicine’s recurring column dedicated to high-value care practice. Leading teaching institutions have built high-value care curricula as a part of their medical student and resident training. However, widespread adoption has been slow and sometimes difficult.

The barriers to adoption of high-value practices among hospitalists are numerous and deep rooted in historical practices and culture. As Dr. Petrilli said, the “culture of overordering [diagnostic tests] is hard to break.” Hospitalists may not have well-developed relationships with patients, or time to explain why some tests or treatments are unnecessary. There is a lack of cost transparency, including the cost of the tests themselves and the downstream costs of additional tests and follow-ups. The best intended interventions fail to produce durable change unless they are seamlessly integrated into a hospitalist’s daily workflow.
 

Six steps to implementing a successful high-value care initiative

What can hospitalists do to improve the value of care they provide to their patients and hospital partners?

1. Identify high-value care opportunities at your hospital.

Dr. Wray pointed out that “all high-value care is local.” Start by looking at the national guidelines and talking to your senior clinical leaders and colleagues. Review your hospital data to identify opportunities and understand the root causes, including variability among providers.

If you choose to analyze and present provider-specific data, first be transparent on why you are doing that. Your goal is not to tell physicians how to practice or to score them, but instead, to promote adoption of evidence-based high-value care by identifying and discussing provider practice variations, and to generate possible solutions. Second, make sure that the data you present is credible and trustworthy by clearly outlining the data source, time frame, sample size per provider, any inclusion and exclusion criteria, attribution logic, and severity adjustment methodology. Third, expect initial pushback as transparency and change can be scary. But most doctors are inherently competitive and will want to be the best at caring for their patients.
 

2. Assemble the team.

Identify an executive sponsor – a senior clinical executive (for example, the chief medical officer or vice president of medical affairs) whose role is to help engage stakeholders, secure resources, and remove barriers. When assembling the rest of the team, include a representative from each major stakeholder group, but keep the team small enough to be effective. For example, if your project focuses on improving telemetry utilization, seek representation from hospitalists, cardiologists, nurses, utilization managers, and possibly IT. Look for people with the relevant knowledge and experience who are respected by their peers and can influence opinion.

3. Design a sustainable solution.

To be sustainable, a solution must be evidence based, well integrated in provider workflow, and have acceptable impact on daily workload (e.g., additional time per patient). If an estimated impact is significant, you need to discuss adding resources or negotiating trade-offs.

A great example of a sustainable solution, aimed to control overutilization of telemetry and urinary catheters, is the one implemented by Dr. Wray and his team.⁷ They designed an EHR-based “silent” indicator that clearly signaled an active telemetry or urinary catheter order for each patient. Clicking on the indicator directed a provider to a “manage order” screen where she could cancel the order, if necessary.
 

4. Engage providers.

You may design the best solution, but it will not succeed unless it is embraced by others. To engage providers, you must clearly communicate why the change is urgently needed for the benefit of their patients, hospital, or community, and appeal to their minds, hearts, and competitive nature.

For example, if you are focusing on overutilization of urinary catheters, you may share your hospital’s urinary catheter device utilization ratio (# of indwelling catheter days/# patient days) against national benchmarks, or the impact on hospital catheter–associated urinary tract infections (CAUTI) rates to appeal to the physicians’ minds. Often, data alone are not enough to move people to action. You must appeal to their hearts by sharing stories of real patients whose lives were affected by preventable CAUTI. Leverage physicians’ competitive nature by using provider-specific data to compare against their peers to spark a discussion.
 

5. Evaluate impact.

Even before you implement a solution, select metrics to measure impact and set SMART (specific, measurable, achievable, relevant, and time-bound) goals. As your implementation moves forward, do not let up or give up – continue to evaluate impact, remove barriers, refine your solution to get back on track if needed, and constantly communicate to share ongoing project results and lessons learned.

6. Sustain improvements.

Sustainable improvements require well-designed solutions integrated into provider workflow, but that is just the first step. Once you demonstrate the impact, consider including the metric (e.g., telemetry or urinary catheter utilization) in your team and/or individual provider performance dashboard, regularly reviewing and discussing performance during your team meetings to maintain engagement, and if needed, making improvements to get back on track.

Successful adoption of high-value care practices requires a disciplined approach to design and implement solutions that are patient-centric, evidence-based, data-driven and integrated in provider workflow.
 

Dr. Farah is a hospitalist, Physician Advisor, and Lean Six Sigma Black Belt. She is a performance improvement consultant based in Corvallis, Ore., and a member of The Hospitalist’s editorial advisory board.

References

1. From the Centers for Medicare & Medicaid Services: National Health Expenditure Projections 2018-2027.

2. Peterson-Kaiser Health System Tracker: How does health spending in the U.S. compare to other countries?

3. Creating a new culture of care, in “Best care at lower cost: The path to continuously learning health care in America.” (Washington: National Academies Press, 2013, pp. 255-80).

4. Choosing Wisely: SHM – Adult Hospital Medicine; Five things physicians and patients should question.

5. Qaseem A et al. Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care. Ann Intern Med. 2012 Jan 17;156(2):147-9.

6. Cho HJ et al. Right care in hospital medicine: Co-creation of ten opportunities in overuse and underuse for improving value in hospital medicine. J Gen Intern Med. 2018 Jun;33(6):804-6.

7. Wray CM et al. Improving value by reducing unnecessary telemetry and urinary catheter utilization in hospitalized patients. Am J Med. 2017 Sep;130(9):1037-41.

U.S. spending on health care is growing rapidly and expected to reach 19.7% of gross domestic product by 2026.¹ In response, the Centers for Medicare and Medicaid Services and national organizations such as the American Board of Internal Medicine (ABIM) and the American College of Physicians (ACP) have launched initiatives to ensure that the value being delivered to patients is on par with the escalating cost of care.

Over the past 10 years, I have led and advised hundreds of small- and large-scale projects that focused on improving patient care quality and cost. Below, I share what I, along with other leaders in high-value care, have observed that it takes to implement successful and lasting improvements – for the benefit of patients and hospitals.
 

A brief history of high-value care

When compared to other wealthy countries, the United States spends disproportionately more money on health care. In 2016, U.S. health care spending was $3.3 trillion¹, or $10,348 per person.² Hospital care alone was responsible for a third of health spending and amounted to $1.1 trillion in 2016¹. By 2026, national health spending is projected to reach $5.7 trillion¹.

In response to escalating health care costs, CMS and other payers have shifted toward value-based reimbursements that tie payments to health care facilities and clinicians to their performance on selected quality, cost, and efficiency measures. For example, under the CMS Merit-based Incentive Payment System (MIPS), 5% of clinicians’ revenue in 2020 is tied to their 2018 performance in four categories: Quality, Cost, Improvement Activities, and Promoting Interoperability. The percentage of revenue at risk will increase to 9% in 2022, based on 2020 performance.

Rising health care costs put a burden not just on the federal and state budgets, but on individual and family budgets as well. Out-of-pocket spending grew 3.9% in 2016 to $352.5 billion¹ and is expected to increase in the future. High health care costs rightfully bring into question the value individual consumers of health care services are getting in return. If value is defined as the level of benefit achieved for a given cost, what is high-value care? The 2013 Institute of Medicine report³ defined high-value care as “the best care for the patient, with the optimal result for the circumstances, delivered at the right price.” It goes beyond a set of quality and cost measures used by payers to affect provider reimbursement and is driven by day-to-day individual providers’ decisions that affect individual patients’ outcomes and their cost of care.

High-value care has been embraced by national organizations. In 2012, the ABIM Foundation launched the Choosing Wisely initiative to support and promote conversations between clinicians and patients in choosing care that is truly necessary, supported by evidence, and free from harm. The result was an evidence-based list of recommendations from 540 specialty societies, including the Society of Hospital Medicine. The SHM – Adult Hospital Medicine list⁴ features the following “Five things physicians and patients should question”:

• Don’t place, or leave in place, urinary catheters for incontinence or convenience or monitoring of output for non–critically ill patients.
• Don’t prescribe medications for stress ulcer prophylaxis to medical inpatients unless at high risk for GI complications.
• Avoid transfusions of red blood cells for arbitrary hemoglobin or hematocrit thresholds and in the absence of symptoms of active coronary disease, heart failure, or stroke.
• Don’t order continuous telemetry monitoring outside of the ICU without using a protocol that governs continuation.
• Don’t perform repetitive CBC and chemistry testing in the face of clinical and lab stability.

The ACP launched a high-value care initiative that offers learning resources for clinicians and medical educators, clinical guidelines, and best practice advice. In 2012, a workgroup of internists convened by ACP developed a list of 37 clinical situations in which medical tests are commonly used but do not provide high value.⁵ Seven of those situations are applicable to adult hospital medicine.
 

High-value care today: What the experts say

More than 5 years later, what progress have hospitalists made in adopting high-value care practices? To answer this and other questions, I reached out to three national experts in high-value care in hospital medicine: Amit Pahwa, MD, assistant professor of medicine and pediatrics at Johns Hopkins University, Baltimore, and a course director of “Topics in interdisciplinary medicine: High-value health care”; Christopher Petrilli, MD, clinical assistant professor in the department of medicine at New York University Langone Health and clinical lead, Manhattan campus, value-based management; and Charlie Wray, DO, MS, assistant professor of medicine at the University of California in San Francisco and a coauthor of an article on high-value care in hospital medicine published recently in the Journal of General Internal Medicine^6.

The experts agree that awareness of high-value care among practicing physicians and medical trainees has increased in the last few years. Major professional publications have highlighted the topic, including The Journal of Hospital Medicine’s “Things We Do For No Reason” series, JAMA’s “Teachable Moments,” and the American Journal of Medicine’s recurring column dedicated to high-value care practice. Leading teaching institutions have built high-value care curricula as a part of their medical student and resident training. However, widespread adoption has been slow and sometimes difficult.

The barriers to adoption of high-value practices among hospitalists are numerous and deep rooted in historical practices and culture. As Dr. Petrilli said, the “culture of overordering [diagnostic tests] is hard to break.” Hospitalists may not have well-developed relationships with patients, or time to explain why some tests or treatments are unnecessary. There is a lack of cost transparency, including the cost of the tests themselves and the downstream costs of additional tests and follow-ups. The best intended interventions fail to produce durable change unless they are seamlessly integrated into a hospitalist’s daily workflow.
 

Six steps to implementing a successful high-value care initiative

What can hospitalists do to improve the value of care they provide to their patients and hospital partners?

1. Identify high-value care opportunities at your hospital.

Dr. Wray pointed out that “all high-value care is local.” Start by looking at the national guidelines and talking to your senior clinical leaders and colleagues. Review your hospital data to identify opportunities and understand the root causes, including variability among providers.

If you choose to analyze and present provider-specific data, first be transparent on why you are doing that. Your goal is not to tell physicians how to practice or to score them, but instead, to promote adoption of evidence-based high-value care by identifying and discussing provider practice variations, and to generate possible solutions. Second, make sure that the data you present is credible and trustworthy by clearly outlining the data source, time frame, sample size per provider, any inclusion and exclusion criteria, attribution logic, and severity adjustment methodology. Third, expect initial pushback as transparency and change can be scary. But most doctors are inherently competitive and will want to be the best at caring for their patients.
 

2. Assemble the team.

Identify an executive sponsor – a senior clinical executive (for example, the chief medical officer or vice president of medical affairs) whose role is to help engage stakeholders, secure resources, and remove barriers. When assembling the rest of the team, include a representative from each major stakeholder group, but keep the team small enough to be effective. For example, if your project focuses on improving telemetry utilization, seek representation from hospitalists, cardiologists, nurses, utilization managers, and possibly IT. Look for people with the relevant knowledge and experience who are respected by their peers and can influence opinion.

3. Design a sustainable solution.

To be sustainable, a solution must be evidence based, well integrated in provider workflow, and have acceptable impact on daily workload (e.g., additional time per patient). If an estimated impact is significant, you need to discuss adding resources or negotiating trade-offs.

A great example of a sustainable solution, aimed to control overutilization of telemetry and urinary catheters, is the one implemented by Dr. Wray and his team.⁷ They designed an EHR-based “silent” indicator that clearly signaled an active telemetry or urinary catheter order for each patient. Clicking on the indicator directed a provider to a “manage order” screen where she could cancel the order, if necessary.
 

4. Engage providers.

You may design the best solution, but it will not succeed unless it is embraced by others. To engage providers, you must clearly communicate why the change is urgently needed for the benefit of their patients, hospital, or community, and appeal to their minds, hearts, and competitive nature.

For example, if you are focusing on overutilization of urinary catheters, you may share your hospital’s urinary catheter device utilization ratio (# of indwelling catheter days/# patient days) against national benchmarks, or the impact on hospital catheter–associated urinary tract infections (CAUTI) rates to appeal to the physicians’ minds. Often, data alone are not enough to move people to action. You must appeal to their hearts by sharing stories of real patients whose lives were affected by preventable CAUTI. Leverage physicians’ competitive nature by using provider-specific data to compare against their peers to spark a discussion.
 

5. Evaluate impact.

Even before you implement a solution, select metrics to measure impact and set SMART (specific, measurable, achievable, relevant, and time-bound) goals. As your implementation moves forward, do not let up or give up – continue to evaluate impact, remove barriers, refine your solution to get back on track if needed, and constantly communicate to share ongoing project results and lessons learned.

6. Sustain improvements.

Sustainable improvements require well-designed solutions integrated into provider workflow, but that is just the first step. Once you demonstrate the impact, consider including the metric (e.g., telemetry or urinary catheter utilization) in your team and/or individual provider performance dashboard, regularly reviewing and discussing performance during your team meetings to maintain engagement, and if needed, making improvements to get back on track.

Successful adoption of high-value care practices requires a disciplined approach to design and implement solutions that are patient-centric, evidence-based, data-driven and integrated in provider workflow.
 

Dr. Farah is a hospitalist, Physician Advisor, and Lean Six Sigma Black Belt. She is a performance improvement consultant based in Corvallis, Ore., and a member of The Hospitalist’s editorial advisory board.

References

1. From the Centers for Medicare & Medicaid Services: National Health Expenditure Projections 2018-2027.

2. Peterson-Kaiser Health System Tracker: How does health spending in the U.S. compare to other countries?

3. Creating a new culture of care, in “Best care at lower cost: The path to continuously learning health care in America.” (Washington: National Academies Press, 2013, pp. 255-80).

4. Choosing Wisely: SHM – Adult Hospital Medicine; Five things physicians and patients should question.

5. Qaseem A et al. Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care. Ann Intern Med. 2012 Jan 17;156(2):147-9.

6. Cho HJ et al. Right care in hospital medicine: Co-creation of ten opportunities in overuse and underuse for improving value in hospital medicine. J Gen Intern Med. 2018 Jun;33(6):804-6.

7. Wray CM et al. Improving value by reducing unnecessary telemetry and urinary catheter utilization in hospitalized patients. Am J Med. 2017 Sep;130(9):1037-41.

U.S. spending on health care is growing rapidly and expected to reach 19.7% of gross domestic product by 2026.¹ In response, the Centers for Medicare and Medicaid Services and national organizations such as the American Board of Internal Medicine (ABIM) and the American College of Physicians (ACP) have launched initiatives to ensure that the value being delivered to patients is on par with the escalating cost of care.

Over the past 10 years, I have led and advised hundreds of small- and large-scale projects that focused on improving patient care quality and cost. Below, I share what I, along with other leaders in high-value care, have observed that it takes to implement successful and lasting improvements – for the benefit of patients and hospitals.
 

A brief history of high-value care

When compared to other wealthy countries, the United States spends disproportionately more money on health care. In 2016, U.S. health care spending was $3.3 trillion¹, or $10,348 per person.² Hospital care alone was responsible for a third of health spending and amounted to $1.1 trillion in 2016¹. By 2026, national health spending is projected to reach $5.7 trillion¹.

In response to escalating health care costs, CMS and other payers have shifted toward value-based reimbursements that tie payments to health care facilities and clinicians to their performance on selected quality, cost, and efficiency measures. For example, under the CMS Merit-based Incentive Payment System (MIPS), 5% of clinicians’ revenue in 2020 is tied to their 2018 performance in four categories: Quality, Cost, Improvement Activities, and Promoting Interoperability. The percentage of revenue at risk will increase to 9% in 2022, based on 2020 performance.

Rising health care costs put a burden not just on the federal and state budgets, but on individual and family budgets as well. Out-of-pocket spending grew 3.9% in 2016 to $352.5 billion¹ and is expected to increase in the future. High health care costs rightfully bring into question the value individual consumers of health care services are getting in return. If value is defined as the level of benefit achieved for a given cost, what is high-value care? The 2013 Institute of Medicine report³ defined high-value care as “the best care for the patient, with the optimal result for the circumstances, delivered at the right price.” It goes beyond a set of quality and cost measures used by payers to affect provider reimbursement and is driven by day-to-day individual providers’ decisions that affect individual patients’ outcomes and their cost of care.

High-value care has been embraced by national organizations. In 2012, the ABIM Foundation launched the Choosing Wisely initiative to support and promote conversations between clinicians and patients in choosing care that is truly necessary, supported by evidence, and free from harm. The result was an evidence-based list of recommendations from 540 specialty societies, including the Society of Hospital Medicine. The SHM – Adult Hospital Medicine list⁴ features the following “Five things physicians and patients should question”:

• Don’t place, or leave in place, urinary catheters for incontinence or convenience or monitoring of output for non–critically ill patients.
• Don’t prescribe medications for stress ulcer prophylaxis to medical inpatients unless at high risk for GI complications.
• Avoid transfusions of red blood cells for arbitrary hemoglobin or hematocrit thresholds and in the absence of symptoms of active coronary disease, heart failure, or stroke.
• Don’t order continuous telemetry monitoring outside of the ICU without using a protocol that governs continuation.
• Don’t perform repetitive CBC and chemistry testing in the face of clinical and lab stability.

The ACP launched a high-value care initiative that offers learning resources for clinicians and medical educators, clinical guidelines, and best practice advice. In 2012, a workgroup of internists convened by ACP developed a list of 37 clinical situations in which medical tests are commonly used but do not provide high value.⁵ Seven of those situations are applicable to adult hospital medicine.
 

High-value care today: What the experts say

More than 5 years later, what progress have hospitalists made in adopting high-value care practices? To answer this and other questions, I reached out to three national experts in high-value care in hospital medicine: Amit Pahwa, MD, assistant professor of medicine and pediatrics at Johns Hopkins University, Baltimore, and a course director of “Topics in interdisciplinary medicine: High-value health care”; Christopher Petrilli, MD, clinical assistant professor in the department of medicine at New York University Langone Health and clinical lead, Manhattan campus, value-based management; and Charlie Wray, DO, MS, assistant professor of medicine at the University of California in San Francisco and a coauthor of an article on high-value care in hospital medicine published recently in the Journal of General Internal Medicine^6.

The experts agree that awareness of high-value care among practicing physicians and medical trainees has increased in the last few years. Major professional publications have highlighted the topic, including The Journal of Hospital Medicine’s “Things We Do For No Reason” series, JAMA’s “Teachable Moments,” and the American Journal of Medicine’s recurring column dedicated to high-value care practice. Leading teaching institutions have built high-value care curricula as a part of their medical student and resident training. However, widespread adoption has been slow and sometimes difficult.

The barriers to adoption of high-value practices among hospitalists are numerous and deep rooted in historical practices and culture. As Dr. Petrilli said, the “culture of overordering [diagnostic tests] is hard to break.” Hospitalists may not have well-developed relationships with patients, or time to explain why some tests or treatments are unnecessary. There is a lack of cost transparency, including the cost of the tests themselves and the downstream costs of additional tests and follow-ups. The best intended interventions fail to produce durable change unless they are seamlessly integrated into a hospitalist’s daily workflow.
 

Six steps to implementing a successful high-value care initiative

What can hospitalists do to improve the value of care they provide to their patients and hospital partners?

1. Identify high-value care opportunities at your hospital.

Dr. Wray pointed out that “all high-value care is local.” Start by looking at the national guidelines and talking to your senior clinical leaders and colleagues. Review your hospital data to identify opportunities and understand the root causes, including variability among providers.

If you choose to analyze and present provider-specific data, first be transparent on why you are doing that. Your goal is not to tell physicians how to practice or to score them, but instead, to promote adoption of evidence-based high-value care by identifying and discussing provider practice variations, and to generate possible solutions. Second, make sure that the data you present is credible and trustworthy by clearly outlining the data source, time frame, sample size per provider, any inclusion and exclusion criteria, attribution logic, and severity adjustment methodology. Third, expect initial pushback as transparency and change can be scary. But most doctors are inherently competitive and will want to be the best at caring for their patients.
 

2. Assemble the team.

Identify an executive sponsor – a senior clinical executive (for example, the chief medical officer or vice president of medical affairs) whose role is to help engage stakeholders, secure resources, and remove barriers. When assembling the rest of the team, include a representative from each major stakeholder group, but keep the team small enough to be effective. For example, if your project focuses on improving telemetry utilization, seek representation from hospitalists, cardiologists, nurses, utilization managers, and possibly IT. Look for people with the relevant knowledge and experience who are respected by their peers and can influence opinion.

3. Design a sustainable solution.

To be sustainable, a solution must be evidence based, well integrated in provider workflow, and have acceptable impact on daily workload (e.g., additional time per patient). If an estimated impact is significant, you need to discuss adding resources or negotiating trade-offs.

A great example of a sustainable solution, aimed to control overutilization of telemetry and urinary catheters, is the one implemented by Dr. Wray and his team.⁷ They designed an EHR-based “silent” indicator that clearly signaled an active telemetry or urinary catheter order for each patient. Clicking on the indicator directed a provider to a “manage order” screen where she could cancel the order, if necessary.
 

4. Engage providers.

You may design the best solution, but it will not succeed unless it is embraced by others. To engage providers, you must clearly communicate why the change is urgently needed for the benefit of their patients, hospital, or community, and appeal to their minds, hearts, and competitive nature.

For example, if you are focusing on overutilization of urinary catheters, you may share your hospital’s urinary catheter device utilization ratio (# of indwelling catheter days/# patient days) against national benchmarks, or the impact on hospital catheter–associated urinary tract infections (CAUTI) rates to appeal to the physicians’ minds. Often, data alone are not enough to move people to action. You must appeal to their hearts by sharing stories of real patients whose lives were affected by preventable CAUTI. Leverage physicians’ competitive nature by using provider-specific data to compare against their peers to spark a discussion.
 

5. Evaluate impact.

Even before you implement a solution, select metrics to measure impact and set SMART (specific, measurable, achievable, relevant, and time-bound) goals. As your implementation moves forward, do not let up or give up – continue to evaluate impact, remove barriers, refine your solution to get back on track if needed, and constantly communicate to share ongoing project results and lessons learned.

6. Sustain improvements.

Sustainable improvements require well-designed solutions integrated into provider workflow, but that is just the first step. Once you demonstrate the impact, consider including the metric (e.g., telemetry or urinary catheter utilization) in your team and/or individual provider performance dashboard, regularly reviewing and discussing performance during your team meetings to maintain engagement, and if needed, making improvements to get back on track.

Successful adoption of high-value care practices requires a disciplined approach to design and implement solutions that are patient-centric, evidence-based, data-driven and integrated in provider workflow.
 

Dr. Farah is a hospitalist, Physician Advisor, and Lean Six Sigma Black Belt. She is a performance improvement consultant based in Corvallis, Ore., and a member of The Hospitalist’s editorial advisory board.

References

1. From the Centers for Medicare & Medicaid Services: National Health Expenditure Projections 2018-2027.

2. Peterson-Kaiser Health System Tracker: How does health spending in the U.S. compare to other countries?

3. Creating a new culture of care, in “Best care at lower cost: The path to continuously learning health care in America.” (Washington: National Academies Press, 2013, pp. 255-80).

4. Choosing Wisely: SHM – Adult Hospital Medicine; Five things physicians and patients should question.

5. Qaseem A et al. Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care. Ann Intern Med. 2012 Jan 17;156(2):147-9.

6. Cho HJ et al. Right care in hospital medicine: Co-creation of ten opportunities in overuse and underuse for improving value in hospital medicine. J Gen Intern Med. 2018 Jun;33(6):804-6.

7. Wray CM et al. Improving value by reducing unnecessary telemetry and urinary catheter utilization in hospitalized patients. Am J Med. 2017 Sep;130(9):1037-41.