The Hospitalist

A blood management initiative that reduced RBC transfusions in the hospital did not adversely impact long-term outcomes after discharge, a retrospective analysis of an extensive patient database suggested.

Vlad/Fotolia

Tolerating moderate in-hospital anemia did not increase subsequent RBC use, readmission, or mortality over the next 6 months, according to results of the study, which drew on nearly half a million patient records.

In fact, modest mortality decreases were seen over time for patients with moderate anemia, perhaps because of concomitant initiatives that targeted infectious and circulatory conditions, reported Nareg H. Roubinian, MD, of Kaiser Permanente Northern California in Oakland and the University of California, San Francisco, and coinvestigators.

“These data support the efficacy and safety of practice recommendations to limit red blood cell transfusion in patients with anemia during and after hospitalization,” Dr. Roubinian and colleagues wrote in their report, which appears in the Annals of Internal Medicine.

However, additional studies are needed to guide anemia management, they wrote, particularly since persistent anemia has impacts on quality of life that are “likely substantial” and linked to the severity of that anemia.

Dr. Roubinian and colleagues sought to evaluate the impact of blood management programs – initiated starting in 2010 – that included blood-sparing surgical and medical techniques, increased use of hemostatic and cell salvage agents, and treatment of suboptimal iron stores before surgery.

In previous retrospective cohort studies, the researchers had found that the blood conservation strategies did not impact in-hospital or 30-day mortality rates, which was consistent with short-term safety data from clinical trials and other observational studies.

Their latest report on longer-term outcomes was based on data from Kaiser Permanente Northern California for 445,371 adults who had 801,261 hospitalizations with discharges between 2010 and 2014. In this cohort, moderate anemia (hemoglobin between 7 g/dL and 10 g/dL) at discharge occurred in 119,489 patients (27%) and 187,440 hospitalizations overall (23%).

Over the 2010-2014 period, RBC transfusions decreased by more than 25% in the inpatient and outpatient settings; and in parallel, the prevalence of moderate anemia at hospital discharge increased from 20% to 25%.

However, the risks of subsequent RBC transfusions and rehospitalization after discharge with anemia decreased during the study period, and mortality rates stayed steady or decreased slightly.

Among patients with moderate anemia, the proportion with subsequent RBC transfusions within 6 months decreased from 18.9% in 2010 to 16.8% in 2014 (P less than .001), while the rate of rehospitalization within 6 months decreased from 36.5% to 32.8% over that same time period (P less than .001).

The adjusted 6-month mortality rate likewise decreased from 16.1% to 15.6% (P = .004) over that time period among patients with moderate anemia.

The study was supported by a grant from the National Heart, Lung, and Blood Institute. Dr. Roubinian and several coauthors reported grants during the conduct of the study from the National Institutes of Health.

SOURCE: Roubinian NH et al. Ann Intern Med. 2018 Dec 18. doi: 10.7326/M17-3253.

A blood management initiative that reduced RBC transfusions in the hospital did not adversely impact long-term outcomes after discharge, a retrospective analysis of an extensive patient database suggested.

Vlad/Fotolia

Tolerating moderate in-hospital anemia did not increase subsequent RBC use, readmission, or mortality over the next 6 months, according to results of the study, which drew on nearly half a million patient records.

In fact, modest mortality decreases were seen over time for patients with moderate anemia, perhaps because of concomitant initiatives that targeted infectious and circulatory conditions, reported Nareg H. Roubinian, MD, of Kaiser Permanente Northern California in Oakland and the University of California, San Francisco, and coinvestigators.

“These data support the efficacy and safety of practice recommendations to limit red blood cell transfusion in patients with anemia during and after hospitalization,” Dr. Roubinian and colleagues wrote in their report, which appears in the Annals of Internal Medicine.

However, additional studies are needed to guide anemia management, they wrote, particularly since persistent anemia has impacts on quality of life that are “likely substantial” and linked to the severity of that anemia.

Dr. Roubinian and colleagues sought to evaluate the impact of blood management programs – initiated starting in 2010 – that included blood-sparing surgical and medical techniques, increased use of hemostatic and cell salvage agents, and treatment of suboptimal iron stores before surgery.

In previous retrospective cohort studies, the researchers had found that the blood conservation strategies did not impact in-hospital or 30-day mortality rates, which was consistent with short-term safety data from clinical trials and other observational studies.

Their latest report on longer-term outcomes was based on data from Kaiser Permanente Northern California for 445,371 adults who had 801,261 hospitalizations with discharges between 2010 and 2014. In this cohort, moderate anemia (hemoglobin between 7 g/dL and 10 g/dL) at discharge occurred in 119,489 patients (27%) and 187,440 hospitalizations overall (23%).

Over the 2010-2014 period, RBC transfusions decreased by more than 25% in the inpatient and outpatient settings; and in parallel, the prevalence of moderate anemia at hospital discharge increased from 20% to 25%.

However, the risks of subsequent RBC transfusions and rehospitalization after discharge with anemia decreased during the study period, and mortality rates stayed steady or decreased slightly.

Among patients with moderate anemia, the proportion with subsequent RBC transfusions within 6 months decreased from 18.9% in 2010 to 16.8% in 2014 (P less than .001), while the rate of rehospitalization within 6 months decreased from 36.5% to 32.8% over that same time period (P less than .001).

The adjusted 6-month mortality rate likewise decreased from 16.1% to 15.6% (P = .004) over that time period among patients with moderate anemia.

The study was supported by a grant from the National Heart, Lung, and Blood Institute. Dr. Roubinian and several coauthors reported grants during the conduct of the study from the National Institutes of Health.

SOURCE: Roubinian NH et al. Ann Intern Med. 2018 Dec 18. doi: 10.7326/M17-3253.

A blood management initiative that reduced RBC transfusions in the hospital did not adversely impact long-term outcomes after discharge, a retrospective analysis of an extensive patient database suggested.

Vlad/Fotolia

Tolerating moderate in-hospital anemia did not increase subsequent RBC use, readmission, or mortality over the next 6 months, according to results of the study, which drew on nearly half a million patient records.

In fact, modest mortality decreases were seen over time for patients with moderate anemia, perhaps because of concomitant initiatives that targeted infectious and circulatory conditions, reported Nareg H. Roubinian, MD, of Kaiser Permanente Northern California in Oakland and the University of California, San Francisco, and coinvestigators.

“These data support the efficacy and safety of practice recommendations to limit red blood cell transfusion in patients with anemia during and after hospitalization,” Dr. Roubinian and colleagues wrote in their report, which appears in the Annals of Internal Medicine.

However, additional studies are needed to guide anemia management, they wrote, particularly since persistent anemia has impacts on quality of life that are “likely substantial” and linked to the severity of that anemia.

Dr. Roubinian and colleagues sought to evaluate the impact of blood management programs – initiated starting in 2010 – that included blood-sparing surgical and medical techniques, increased use of hemostatic and cell salvage agents, and treatment of suboptimal iron stores before surgery.

In previous retrospective cohort studies, the researchers had found that the blood conservation strategies did not impact in-hospital or 30-day mortality rates, which was consistent with short-term safety data from clinical trials and other observational studies.

Their latest report on longer-term outcomes was based on data from Kaiser Permanente Northern California for 445,371 adults who had 801,261 hospitalizations with discharges between 2010 and 2014. In this cohort, moderate anemia (hemoglobin between 7 g/dL and 10 g/dL) at discharge occurred in 119,489 patients (27%) and 187,440 hospitalizations overall (23%).

Over the 2010-2014 period, RBC transfusions decreased by more than 25% in the inpatient and outpatient settings; and in parallel, the prevalence of moderate anemia at hospital discharge increased from 20% to 25%.

However, the risks of subsequent RBC transfusions and rehospitalization after discharge with anemia decreased during the study period, and mortality rates stayed steady or decreased slightly.

Among patients with moderate anemia, the proportion with subsequent RBC transfusions within 6 months decreased from 18.9% in 2010 to 16.8% in 2014 (P less than .001), while the rate of rehospitalization within 6 months decreased from 36.5% to 32.8% over that same time period (P less than .001).

The adjusted 6-month mortality rate likewise decreased from 16.1% to 15.6% (P = .004) over that time period among patients with moderate anemia.

The study was supported by a grant from the National Heart, Lung, and Blood Institute. Dr. Roubinian and several coauthors reported grants during the conduct of the study from the National Institutes of Health.

SOURCE: Roubinian NH et al. Ann Intern Med. 2018 Dec 18. doi: 10.7326/M17-3253.

Compared with placebo, opioids provide very modest improvements in chronic noncancer pain and physical functioning that decrease over time, according to the authors of a systematic review and meta-analysis of nearly 100 randomized clinical trials.

There was little difference in pain control between opioids and nonopioid alternatives such as NSAIDs in a subset of nine such comparative trials, reported the authors, led by Jason W. Busse, DC, PhD, of the department of anesthesia at McMaster University, Hamilton, Ont.

Pain benefits of opioids decreased over time in longer trials, possibly because of opioid tolerance or hyperalgesia, a condition marked by hypersensitivity to pain. “A reduced association with benefit over time might lead to prescription of higher opioid doses and consequent harms,” Dr. Busse and his coauthors wrote in JAMA.

The meta-analysis included 96 randomized clinical trials including 26,169 patients with chronic noncancer pain.

Opioid treatment did significantly improve pain and physical function versus placebo, though the magnitude of benefit was small, according to the investigators. The reduction in pain was –0.69 cm on a 10-cm visual analog scale (P less than .001), based on high-quality evidence from 42 randomized, controlled trials that followed patients for at least 3 months.

The improvement in physical functioning was likewise significant but small at 2.04 out of 100 points on the SF-36 physical component score (P less than .001). Emotional and role functioning were not significantly improved by opioid use.

Opioid use was linked to increased vomiting incidence versus placebo, with a relative risk of 4.12 (95% CI, 3.34-5.07; P less than .001) for patients in “nonenrichment” trials – those studies that included all patients regardless of whether or not they reported lack of improvement or had substantial adverse events during a study run-in period.

Nausea, constipation, dizziness, drowsiness, pruritus, and dry mouth were also linked to opioid use as compared with placebo, Dr. Busse and his colleagues reported.

The benefit of opioids and nonopioid alternatives appeared to be similar in this meta-analysis, though the available evidence from comparative studies was of low to moderate quality, the authors advised.

In moderate-quality evidence from nine clinical trials of opioids versus NSAIDs including 1,431 patients, there was no difference in pain relief between the two interventions, the investigators said. Moreover, comparisons of physician functioning also suggested no difference, while opioids were associated with more vomiting.

Both tricyclic antidepressants and synthetic cannabinoids offered similar pain relief, compared with opioids, based on low-quality clinical trial evidence, they added, while moderate-quality evidence suggested opioids offered superior pain relief, compared with anticonvulsants.

Support for the study came from the Canadian Institutes of Health Research and Health Canada. One study coauthor reported receiving personal fees from Purdue Pharma and the Nova Scotia College of Physicians and Surgeons.

SOURCE: Busse JW et al. JAMA. 2018;320(23):2448-60.

Compared with placebo, opioids provide very modest improvements in chronic noncancer pain and physical functioning that decrease over time, according to the authors of a systematic review and meta-analysis of nearly 100 randomized clinical trials.

There was little difference in pain control between opioids and nonopioid alternatives such as NSAIDs in a subset of nine such comparative trials, reported the authors, led by Jason W. Busse, DC, PhD, of the department of anesthesia at McMaster University, Hamilton, Ont.

Pain benefits of opioids decreased over time in longer trials, possibly because of opioid tolerance or hyperalgesia, a condition marked by hypersensitivity to pain. “A reduced association with benefit over time might lead to prescription of higher opioid doses and consequent harms,” Dr. Busse and his coauthors wrote in JAMA.

The meta-analysis included 96 randomized clinical trials including 26,169 patients with chronic noncancer pain.

Opioid treatment did significantly improve pain and physical function versus placebo, though the magnitude of benefit was small, according to the investigators. The reduction in pain was –0.69 cm on a 10-cm visual analog scale (P less than .001), based on high-quality evidence from 42 randomized, controlled trials that followed patients for at least 3 months.

The improvement in physical functioning was likewise significant but small at 2.04 out of 100 points on the SF-36 physical component score (P less than .001). Emotional and role functioning were not significantly improved by opioid use.

Opioid use was linked to increased vomiting incidence versus placebo, with a relative risk of 4.12 (95% CI, 3.34-5.07; P less than .001) for patients in “nonenrichment” trials – those studies that included all patients regardless of whether or not they reported lack of improvement or had substantial adverse events during a study run-in period.

Nausea, constipation, dizziness, drowsiness, pruritus, and dry mouth were also linked to opioid use as compared with placebo, Dr. Busse and his colleagues reported.

The benefit of opioids and nonopioid alternatives appeared to be similar in this meta-analysis, though the available evidence from comparative studies was of low to moderate quality, the authors advised.

In moderate-quality evidence from nine clinical trials of opioids versus NSAIDs including 1,431 patients, there was no difference in pain relief between the two interventions, the investigators said. Moreover, comparisons of physician functioning also suggested no difference, while opioids were associated with more vomiting.

Both tricyclic antidepressants and synthetic cannabinoids offered similar pain relief, compared with opioids, based on low-quality clinical trial evidence, they added, while moderate-quality evidence suggested opioids offered superior pain relief, compared with anticonvulsants.

Support for the study came from the Canadian Institutes of Health Research and Health Canada. One study coauthor reported receiving personal fees from Purdue Pharma and the Nova Scotia College of Physicians and Surgeons.

SOURCE: Busse JW et al. JAMA. 2018;320(23):2448-60.

Compared with placebo, opioids provide very modest improvements in chronic noncancer pain and physical functioning that decrease over time, according to the authors of a systematic review and meta-analysis of nearly 100 randomized clinical trials.

There was little difference in pain control between opioids and nonopioid alternatives such as NSAIDs in a subset of nine such comparative trials, reported the authors, led by Jason W. Busse, DC, PhD, of the department of anesthesia at McMaster University, Hamilton, Ont.

Pain benefits of opioids decreased over time in longer trials, possibly because of opioid tolerance or hyperalgesia, a condition marked by hypersensitivity to pain. “A reduced association with benefit over time might lead to prescription of higher opioid doses and consequent harms,” Dr. Busse and his coauthors wrote in JAMA.

The meta-analysis included 96 randomized clinical trials including 26,169 patients with chronic noncancer pain.

Opioid treatment did significantly improve pain and physical function versus placebo, though the magnitude of benefit was small, according to the investigators. The reduction in pain was –0.69 cm on a 10-cm visual analog scale (P less than .001), based on high-quality evidence from 42 randomized, controlled trials that followed patients for at least 3 months.

The improvement in physical functioning was likewise significant but small at 2.04 out of 100 points on the SF-36 physical component score (P less than .001). Emotional and role functioning were not significantly improved by opioid use.

Opioid use was linked to increased vomiting incidence versus placebo, with a relative risk of 4.12 (95% CI, 3.34-5.07; P less than .001) for patients in “nonenrichment” trials – those studies that included all patients regardless of whether or not they reported lack of improvement or had substantial adverse events during a study run-in period.

Nausea, constipation, dizziness, drowsiness, pruritus, and dry mouth were also linked to opioid use as compared with placebo, Dr. Busse and his colleagues reported.

The benefit of opioids and nonopioid alternatives appeared to be similar in this meta-analysis, though the available evidence from comparative studies was of low to moderate quality, the authors advised.

In moderate-quality evidence from nine clinical trials of opioids versus NSAIDs including 1,431 patients, there was no difference in pain relief between the two interventions, the investigators said. Moreover, comparisons of physician functioning also suggested no difference, while opioids were associated with more vomiting.

Both tricyclic antidepressants and synthetic cannabinoids offered similar pain relief, compared with opioids, based on low-quality clinical trial evidence, they added, while moderate-quality evidence suggested opioids offered superior pain relief, compared with anticonvulsants.

Support for the study came from the Canadian Institutes of Health Research and Health Canada. One study coauthor reported receiving personal fees from Purdue Pharma and the Nova Scotia College of Physicians and Surgeons.

SOURCE: Busse JW et al. JAMA. 2018;320(23):2448-60.

CHICAGO – High-risk hospitalized patients with atrial fibrillation (AF) whose doctors monitored them with a computerized alert system were more than twice as likely to be on anticoagulation and had significantly lower rates of death and other cardiovascular events, compared with patients on a standard admissions protocol, according to results of a randomized, controlled trial presented at the American Heart Association Scientific Sessions.

“Alert-based computerized decision support [CDS] increased the prescription of anticoagulation for stroke prevention in atrial fibrillation during hospitalization, at discharge, and at 90 days after randomization in high-risk patients,” said Gregory Piazza, MD, of Brigham and Women’s Hospital, Boston, in presenting results of the AF-ALERT trial. “The reductions in major cardiovascular events was attributable to reductions in MI and stroke/transient ischemic attack at 90 days in patients whose physicians received the alert.”

The trial evaluated 458 patients hospitalized for AF or flutter and with CHA2DS2-VASc scores of 1-8 randomly assigned to the alert (n = 258) or no-alert (n = 210) groups.

Dr. Piazza explained that for those in the alert group, the CDS system notified physicians when the patient’s CHA₂DS₂-VASc score increased. From there, the physician could choose to open an order template to prescribe evidence-based medications to prevent stroke, to elect to review evidence-based clinical practice guidelines, or to continue with the admissions order with an acknowledged reason for omitting anticoagulation (such as high bleeding risk, low stroke risk, high risk for falls, or patient refusal of anticoagulation).

“In patients for whom their providers were alerted, 35% elected to open the stroke-prevention order set, a very tiny percentage elected to read the AF guidelines, and about 64% exited but provided a rationale for omitting anticoagulation,” Dr. Piazza noted.

The alert group was far more likely to be prescribed anticoagulation during the hospitalization (25.8% vs. 9.5%; P less than .0001), at discharge (23.8% vs. 12.9%; P = .003), and at 90 days (27.7% vs. 17.1%; P = .007) than the control group. The alert resulted in a 55% relative risk reduction in a composite outcome of death, MI, cerebrovascular event, and systemic embolic event at 90 days (11.3% vs. 21.9%; P = .002). The alert group had an 87% lower incidence of MI at 90 days (1.2% vs. 8.6%, P = .0002) and 88% lower incidence of cerebrovascular events or systemic embolism at 90 days (0% vs. 2.4%; P = .02). Death at 90 days occurred in 10.1% in the alert group and 14.8% in the control group (P = .13).

One of the limitations of the study, Dr. Piazza noted, was that the most dramatic finding – reduction of major cardiovascular events – was a secondary, not a primary, endpoint. “CDS has the potential to be a powerful tool in prevention of cardiovascular events in patients with atrial fibrillation.”

Moderator Mintu Turakhia, MD, of Stanford (Calif.) University, questioned the low rate of anticoagulation in the study’s control arm – 9.5% – much lower than medians reported in many registries. He also asked Dr. Piazza to describe the mechanism of action for prescribing anticoagulation in these patients.

Dr. Piazza noted the study population was hospitalized patients whose providers had decided prior to their admissions not to prescribe anticoagulation; hence, the rate of anticoagulation in these patients was actually higher than expected.

Regarding the mechanism of action, “the electronic alert seems to preferentially increase the prescription of [direct oral anticoagulants] over warfarin, and that may have been one of the mechanisms,” Dr. Piazza said. Another explanation he offered were “off-target” effects whereby, if providers have a better idea of a patient’s risk for a stroke or MI, they’ll be more aggressive about managing other risk factors.

“There are a number of interventions that could be triggered if the alert prompted the provider to have a conversation with patients about their risk of stroke from AF,” he said. “This may have impact beyond what we can tell from this simple [Best Practice Advisory in the Epic EHR system]. I think we don’t have a great understanding of the full mechanisms of CDS.”

Dr. Piazza reported financial relationships with BTG, Janssen, Bristol-Myers Squibb, Daiichi Sankyo, Portola, and Bayer. Daiichi Sankyo funded the trial. Dr. Turakhia reported relationships with Apple, Janssen, AstraZeneca, VA, Boehringer Ingelheim, Cardiva Medical, Medtronic, Abbott, Precision Health Economics, iBeat, iRhythm, MyoKardia, Biotronik, and an ownership Interest in AliveCor.

CHICAGO – High-risk hospitalized patients with atrial fibrillation (AF) whose doctors monitored them with a computerized alert system were more than twice as likely to be on anticoagulation and had significantly lower rates of death and other cardiovascular events, compared with patients on a standard admissions protocol, according to results of a randomized, controlled trial presented at the American Heart Association Scientific Sessions.

“Alert-based computerized decision support [CDS] increased the prescription of anticoagulation for stroke prevention in atrial fibrillation during hospitalization, at discharge, and at 90 days after randomization in high-risk patients,” said Gregory Piazza, MD, of Brigham and Women’s Hospital, Boston, in presenting results of the AF-ALERT trial. “The reductions in major cardiovascular events was attributable to reductions in MI and stroke/transient ischemic attack at 90 days in patients whose physicians received the alert.”

The trial evaluated 458 patients hospitalized for AF or flutter and with CHA2DS2-VASc scores of 1-8 randomly assigned to the alert (n = 258) or no-alert (n = 210) groups.

Dr. Piazza explained that for those in the alert group, the CDS system notified physicians when the patient’s CHA₂DS₂-VASc score increased. From there, the physician could choose to open an order template to prescribe evidence-based medications to prevent stroke, to elect to review evidence-based clinical practice guidelines, or to continue with the admissions order with an acknowledged reason for omitting anticoagulation (such as high bleeding risk, low stroke risk, high risk for falls, or patient refusal of anticoagulation).

“In patients for whom their providers were alerted, 35% elected to open the stroke-prevention order set, a very tiny percentage elected to read the AF guidelines, and about 64% exited but provided a rationale for omitting anticoagulation,” Dr. Piazza noted.

The alert group was far more likely to be prescribed anticoagulation during the hospitalization (25.8% vs. 9.5%; P less than .0001), at discharge (23.8% vs. 12.9%; P = .003), and at 90 days (27.7% vs. 17.1%; P = .007) than the control group. The alert resulted in a 55% relative risk reduction in a composite outcome of death, MI, cerebrovascular event, and systemic embolic event at 90 days (11.3% vs. 21.9%; P = .002). The alert group had an 87% lower incidence of MI at 90 days (1.2% vs. 8.6%, P = .0002) and 88% lower incidence of cerebrovascular events or systemic embolism at 90 days (0% vs. 2.4%; P = .02). Death at 90 days occurred in 10.1% in the alert group and 14.8% in the control group (P = .13).

One of the limitations of the study, Dr. Piazza noted, was that the most dramatic finding – reduction of major cardiovascular events – was a secondary, not a primary, endpoint. “CDS has the potential to be a powerful tool in prevention of cardiovascular events in patients with atrial fibrillation.”

Moderator Mintu Turakhia, MD, of Stanford (Calif.) University, questioned the low rate of anticoagulation in the study’s control arm – 9.5% – much lower than medians reported in many registries. He also asked Dr. Piazza to describe the mechanism of action for prescribing anticoagulation in these patients.

Dr. Piazza noted the study population was hospitalized patients whose providers had decided prior to their admissions not to prescribe anticoagulation; hence, the rate of anticoagulation in these patients was actually higher than expected.

Regarding the mechanism of action, “the electronic alert seems to preferentially increase the prescription of [direct oral anticoagulants] over warfarin, and that may have been one of the mechanisms,” Dr. Piazza said. Another explanation he offered were “off-target” effects whereby, if providers have a better idea of a patient’s risk for a stroke or MI, they’ll be more aggressive about managing other risk factors.

“There are a number of interventions that could be triggered if the alert prompted the provider to have a conversation with patients about their risk of stroke from AF,” he said. “This may have impact beyond what we can tell from this simple [Best Practice Advisory in the Epic EHR system]. I think we don’t have a great understanding of the full mechanisms of CDS.”

Dr. Piazza reported financial relationships with BTG, Janssen, Bristol-Myers Squibb, Daiichi Sankyo, Portola, and Bayer. Daiichi Sankyo funded the trial. Dr. Turakhia reported relationships with Apple, Janssen, AstraZeneca, VA, Boehringer Ingelheim, Cardiva Medical, Medtronic, Abbott, Precision Health Economics, iBeat, iRhythm, MyoKardia, Biotronik, and an ownership Interest in AliveCor.

CHICAGO – High-risk hospitalized patients with atrial fibrillation (AF) whose doctors monitored them with a computerized alert system were more than twice as likely to be on anticoagulation and had significantly lower rates of death and other cardiovascular events, compared with patients on a standard admissions protocol, according to results of a randomized, controlled trial presented at the American Heart Association Scientific Sessions.

“Alert-based computerized decision support [CDS] increased the prescription of anticoagulation for stroke prevention in atrial fibrillation during hospitalization, at discharge, and at 90 days after randomization in high-risk patients,” said Gregory Piazza, MD, of Brigham and Women’s Hospital, Boston, in presenting results of the AF-ALERT trial. “The reductions in major cardiovascular events was attributable to reductions in MI and stroke/transient ischemic attack at 90 days in patients whose physicians received the alert.”

The trial evaluated 458 patients hospitalized for AF or flutter and with CHA2DS2-VASc scores of 1-8 randomly assigned to the alert (n = 258) or no-alert (n = 210) groups.

Dr. Piazza explained that for those in the alert group, the CDS system notified physicians when the patient’s CHA₂DS₂-VASc score increased. From there, the physician could choose to open an order template to prescribe evidence-based medications to prevent stroke, to elect to review evidence-based clinical practice guidelines, or to continue with the admissions order with an acknowledged reason for omitting anticoagulation (such as high bleeding risk, low stroke risk, high risk for falls, or patient refusal of anticoagulation).

“In patients for whom their providers were alerted, 35% elected to open the stroke-prevention order set, a very tiny percentage elected to read the AF guidelines, and about 64% exited but provided a rationale for omitting anticoagulation,” Dr. Piazza noted.

The alert group was far more likely to be prescribed anticoagulation during the hospitalization (25.8% vs. 9.5%; P less than .0001), at discharge (23.8% vs. 12.9%; P = .003), and at 90 days (27.7% vs. 17.1%; P = .007) than the control group. The alert resulted in a 55% relative risk reduction in a composite outcome of death, MI, cerebrovascular event, and systemic embolic event at 90 days (11.3% vs. 21.9%; P = .002). The alert group had an 87% lower incidence of MI at 90 days (1.2% vs. 8.6%, P = .0002) and 88% lower incidence of cerebrovascular events or systemic embolism at 90 days (0% vs. 2.4%; P = .02). Death at 90 days occurred in 10.1% in the alert group and 14.8% in the control group (P = .13).

One of the limitations of the study, Dr. Piazza noted, was that the most dramatic finding – reduction of major cardiovascular events – was a secondary, not a primary, endpoint. “CDS has the potential to be a powerful tool in prevention of cardiovascular events in patients with atrial fibrillation.”

Moderator Mintu Turakhia, MD, of Stanford (Calif.) University, questioned the low rate of anticoagulation in the study’s control arm – 9.5% – much lower than medians reported in many registries. He also asked Dr. Piazza to describe the mechanism of action for prescribing anticoagulation in these patients.

Dr. Piazza noted the study population was hospitalized patients whose providers had decided prior to their admissions not to prescribe anticoagulation; hence, the rate of anticoagulation in these patients was actually higher than expected.

Regarding the mechanism of action, “the electronic alert seems to preferentially increase the prescription of [direct oral anticoagulants] over warfarin, and that may have been one of the mechanisms,” Dr. Piazza said. Another explanation he offered were “off-target” effects whereby, if providers have a better idea of a patient’s risk for a stroke or MI, they’ll be more aggressive about managing other risk factors.

“There are a number of interventions that could be triggered if the alert prompted the provider to have a conversation with patients about their risk of stroke from AF,” he said. “This may have impact beyond what we can tell from this simple [Best Practice Advisory in the Epic EHR system]. I think we don’t have a great understanding of the full mechanisms of CDS.”

Dr. Piazza reported financial relationships with BTG, Janssen, Bristol-Myers Squibb, Daiichi Sankyo, Portola, and Bayer. Daiichi Sankyo funded the trial. Dr. Turakhia reported relationships with Apple, Janssen, AstraZeneca, VA, Boehringer Ingelheim, Cardiva Medical, Medtronic, Abbott, Precision Health Economics, iBeat, iRhythm, MyoKardia, Biotronik, and an ownership Interest in AliveCor.

The U.S. Preventive Services Task Force posted a draft research plan on opioid use disorder prevention for public comment on Dec. 13, according to a USPSTF bulletin.

An estimated 2.1 million persons aged 12 years and older had an opioid use disorder in 2017, and opioids were involved in nearly two-thirds of more than 70,000 fatal drug overdoses, according to the task force. Prevention of unnecessary opioid use, opioid misuse, and opioid use disorder in primary care settings is necessary to effectively respond to the ongoing crisis.

In an extensive literature review, an independent research team will look for evidence on strategies for people not currently receiving opioids that can be implemented on the primary care level. The public is invited to submit comments on the research plan that will help focus and guide the literature review.

The USPSTF also will be updating the current 2008 recommendation statement on screening for illicit drugs and nonmedical prescription drugs in adolescents and young adults, including pregnant and postpartum women.

Comments can be submitted until Jan. 16, 2019, on the USPSTF website.

[email protected]

The U.S. Preventive Services Task Force posted a draft research plan on opioid use disorder prevention for public comment on Dec. 13, according to a USPSTF bulletin.

An estimated 2.1 million persons aged 12 years and older had an opioid use disorder in 2017, and opioids were involved in nearly two-thirds of more than 70,000 fatal drug overdoses, according to the task force. Prevention of unnecessary opioid use, opioid misuse, and opioid use disorder in primary care settings is necessary to effectively respond to the ongoing crisis.

In an extensive literature review, an independent research team will look for evidence on strategies for people not currently receiving opioids that can be implemented on the primary care level. The public is invited to submit comments on the research plan that will help focus and guide the literature review.

The USPSTF also will be updating the current 2008 recommendation statement on screening for illicit drugs and nonmedical prescription drugs in adolescents and young adults, including pregnant and postpartum women.

Comments can be submitted until Jan. 16, 2019, on the USPSTF website.

[email protected]

The U.S. Preventive Services Task Force posted a draft research plan on opioid use disorder prevention for public comment on Dec. 13, according to a USPSTF bulletin.

An estimated 2.1 million persons aged 12 years and older had an opioid use disorder in 2017, and opioids were involved in nearly two-thirds of more than 70,000 fatal drug overdoses, according to the task force. Prevention of unnecessary opioid use, opioid misuse, and opioid use disorder in primary care settings is necessary to effectively respond to the ongoing crisis.

In an extensive literature review, an independent research team will look for evidence on strategies for people not currently receiving opioids that can be implemented on the primary care level. The public is invited to submit comments on the research plan that will help focus and guide the literature review.

The USPSTF also will be updating the current 2008 recommendation statement on screening for illicit drugs and nonmedical prescription drugs in adolescents and young adults, including pregnant and postpartum women.

Comments can be submitted until Jan. 16, 2019, on the USPSTF website.

[email protected]

The world’s largest gay dating app, Grindr, changed its software earlier this year to create reminders for users to get regular HIV tests.

jarun011/Thinkstock

According to Grindr, 3.3 million users around the world visit the site daily; it sends those who opt into the service a reminder every 3-6 months to get a test. The message also directs them to the nearest testing site. Grindr also plans to give clinics, gay community centers, and other testing sites free advertising.

Among health care providers, the decision has been widely applauded. “This will ‘demedicalize’ testing and destigmatize it,” Perry N. Halkitis, PhD, dean of the Rutgers School of Public Health, in Newark, N.J., told the New York Times. “The more you make it normal, the more people are going to access it.”

Studies have shown that reminders by text or phone can triple or quadruple the chance that the recipient will get tested.
 

Reference

McNeil Jr. DG. Grindr App to Offer H.I.V. Test Reminders. The New York Times. March 26, 2018. Accessed April 5, 2018.






 

The world’s largest gay dating app, Grindr, changed its software earlier this year to create reminders for users to get regular HIV tests.

jarun011/Thinkstock

According to Grindr, 3.3 million users around the world visit the site daily; it sends those who opt into the service a reminder every 3-6 months to get a test. The message also directs them to the nearest testing site. Grindr also plans to give clinics, gay community centers, and other testing sites free advertising.

Among health care providers, the decision has been widely applauded. “This will ‘demedicalize’ testing and destigmatize it,” Perry N. Halkitis, PhD, dean of the Rutgers School of Public Health, in Newark, N.J., told the New York Times. “The more you make it normal, the more people are going to access it.”

Studies have shown that reminders by text or phone can triple or quadruple the chance that the recipient will get tested.
 

Reference

McNeil Jr. DG. Grindr App to Offer H.I.V. Test Reminders. The New York Times. March 26, 2018. Accessed April 5, 2018.






 

The world’s largest gay dating app, Grindr, changed its software earlier this year to create reminders for users to get regular HIV tests.

jarun011/Thinkstock

According to Grindr, 3.3 million users around the world visit the site daily; it sends those who opt into the service a reminder every 3-6 months to get a test. The message also directs them to the nearest testing site. Grindr also plans to give clinics, gay community centers, and other testing sites free advertising.

Among health care providers, the decision has been widely applauded. “This will ‘demedicalize’ testing and destigmatize it,” Perry N. Halkitis, PhD, dean of the Rutgers School of Public Health, in Newark, N.J., told the New York Times. “The more you make it normal, the more people are going to access it.”

Studies have shown that reminders by text or phone can triple or quadruple the chance that the recipient will get tested.
 

Reference

McNeil Jr. DG. Grindr App to Offer H.I.V. Test Reminders. The New York Times. March 26, 2018. Accessed April 5, 2018.






 

A group of internists is suing the American Board of Internal Medicine over its maintenance of certification (MOC) process, alleging that the board is monopolizing the MOC market.

jsmith/iStockphoto

The lawsuit, filed Dec. 6 in Pennsylvania district court, claims that ABIM is charging inflated monopoly prices for maintaining certification, that the organization is forcing physicians to purchase MOC, and that ABIM is inducing employers and others to require ABIM certification. The four plaintiff-physicians are asking a judge to find ABIM in violation of federal antitrust law and to bar the board from continuing its MOC process. The suit is filed as a class action on behalf of all internists and subspecialists required by ABIM to purchase MOC to maintain their ABIM certifications. The plaintiffs seek damages and injunctive relief, plus lawsuit and attorney costs arising from ABIM’s alleged antitrust violations.

In a statement, ABIM expressed disappointment at the lawsuit and said the organization will vigorously defend itself, adding that doing so will “consume resources far better dedicated to continuous improvement of its programs.”

ABIM declined to answer questions addressing specific accusations from the lawsuit. However, in an interview, ABIM President Richard Baron, MD, said that “ABIM board-certified physicians have taken the initiative to distinguish themselves. This is a credential that physicians earn. We offer certified physicians the opportunity to demonstrate to the medical community, their peers, and the public that they are current and have special expertise.”

ABIM has not yet filed a formal response to the lawsuit, which was due by Jan. 6. Court documents show that in January, ABIM entered the appearances of four attorneys that will represent the board in the case. From there, discovery and evidence gathering in the case will begin.

Katherine Murray Leisure, MD, an infectious disease specialist based in Plymouth, Mass., is one of the plaintiffs. While she said that she could not comment specifically on the lawsuit, she has written publicly about her ABIM concerns in the past.

In a 2015 letter to Dr. Baron and posted on an anti-MOC website, Dr. Murray outlined a litany of complaints against ABIM’s MOC process and called on the U.S. Congress to investigate ABIM’s financial, legal, and ethical conduct.

“[The American Board of Medical Specialties] and ABIM collected more than $10,000 in fees and lost practice hours every decade from each [diplomate] doing MOC,” Dr. Murray Leisure wrote. “MOC took weeks away from our offices, clinics, patients, families, specialty societies, and individual research. ABMS MOC removed hundreds, perhaps thousands … of America’s best, once board-certified physicians from full hospital careers and earnings whenever [diplomates] did not complete these high-stakes MOC programs. … The righteous and fast solution to such moral, ethical, scientific, and constitutional problems is to end MOC now.”

Plaintiffs Glen Dela Cruz Manalo, MD; Alexa Joshua, MD; and Gerard Kenney, MD, did not return messages seeking comment. When contacted, attorneys for the plaintiffs declined to comment.

The doctors’ 32-page lawsuit characterizes ABIM as an organization motivated by money that has made its MOC process increasingly more burdensome for physicians over the years without evidence that MOC has any beneficial impact on doctors, patients, or the public. Complying with ABIM’s MOC costs internists an average of $23,607 in financial cost and time lost over 10 years, and costs up to $40,495 for some specialists, according to the suit.

The physicians allege that ABIM controls in excess of 95% of the market for MOC of internists, in violation of federal antitrust laws, and that the organization has unlawfully obtained and maintained monopoly power for MOC services.

The board’s illegal tying of its initial certification to its MOC results in burdensome conditions, including “raising the cost of the practice of medicine, constraining the supply of internists thereby harming competition, decreasing the supply of certified internists, and increasing the cost of medical services to patients and consumers,” the suit claims.

The legal challenge details how MOC has personally and professionally impacted each of the four plaintiffs. Dr. Manalo, a gastroenterologist, lost his privileges at St. Vincent Healthcare in Billings, Mont., and was subsequently terminated after he declined to maintain his ABIM certification as a gastroenterologist. In a letter to ABIM, Dr. Manalo wrote that it was “unfair and outright discriminatory that practitioners certified on or after 1990 are the only ones required to certify,” according to the lawsuit. Dr. Manalo later took a position as staff gastroenterologist at Jonathan M. Wainwright Memorial Veterans Affairs Medical Center in Walla Walla, Wash., at a substantially reduced salary. He became unemployed in 2017.

Dr. Murray Leisure obtained an initial and lifelong board certification in internal medicine from ABIM in 1984 and an infectious disease certification in 1990. ABlM terminated Dr. Murray’s infectious diseases certification after she failed her MOC examination in 2009, which led to lost privileges at Jordan Hospital in Plymouth, Mass. The loss caused significant damage to Dr. Murray, including lost income, a tarnished reputation, and the lost opportunity to help patients, according to the lawsuit. Jordan Hospital restored her privileges after Dr. Murray passed her MOC examination in 2012.

Dr. Kenney lost a job opportunity with Mount Nittany Physicians Group in State College, Pa., after he declined to renew his ABIM certification in gastroenterology. He is currently a physician with the University of Pittsburgh Medical Center in Seneca, Pa.

That the ABIM website lists him as “not certified,” is misleading, and makes it appear that his initial certifications were revoked due to failure to pass a MOC examination or misconduct, rather than because the certifications lapsed, according to the suit. The description makes Dr. Kenney appear less qualified to patients, hospitals, insurance companies, medical corporations, other employers, and others, he claims.

Dr. Joshua could not renew her consulting and admitting privileges at Detroit Medical Center after she failed an MOC examination in 2014 and became uncertified in internal medicine, according to the suit. In addition, Blue Cross Blue Shield informed Dr. Joshua it would no longer cover her because it required ABIM certification for coverage. She unsuccessfully appealed based on her certification with the National Board of Physicians and Surgeons. As a result of her certification termination, Dr. Joshua can only practice outpatient medicine at Detroit Medical Center.

In an interview, Dr. Baron emphasized the number of modifications made to its MOC process in recent years after responding to physician concerns. This includes an overhaul of the organization’s governance structure to include more than 200 practicing physicians and opening new avenues for physicians to engage in the creation of assessment content that more closely reflects what they see in practice, he said. In addition, ABIM now surveys all specialists to contribute to the exam blueprint review and the creation of the new Item Writing Task Force.

*This story was updated on Feb. 6, 2019.

A group of internists is suing the American Board of Internal Medicine over its maintenance of certification (MOC) process, alleging that the board is monopolizing the MOC market.

jsmith/iStockphoto

The lawsuit, filed Dec. 6 in Pennsylvania district court, claims that ABIM is charging inflated monopoly prices for maintaining certification, that the organization is forcing physicians to purchase MOC, and that ABIM is inducing employers and others to require ABIM certification. The four plaintiff-physicians are asking a judge to find ABIM in violation of federal antitrust law and to bar the board from continuing its MOC process. The suit is filed as a class action on behalf of all internists and subspecialists required by ABIM to purchase MOC to maintain their ABIM certifications. The plaintiffs seek damages and injunctive relief, plus lawsuit and attorney costs arising from ABIM’s alleged antitrust violations.

In a statement, ABIM expressed disappointment at the lawsuit and said the organization will vigorously defend itself, adding that doing so will “consume resources far better dedicated to continuous improvement of its programs.”

ABIM declined to answer questions addressing specific accusations from the lawsuit. However, in an interview, ABIM President Richard Baron, MD, said that “ABIM board-certified physicians have taken the initiative to distinguish themselves. This is a credential that physicians earn. We offer certified physicians the opportunity to demonstrate to the medical community, their peers, and the public that they are current and have special expertise.”

ABIM has not yet filed a formal response to the lawsuit, which was due by Jan. 6. Court documents show that in January, ABIM entered the appearances of four attorneys that will represent the board in the case. From there, discovery and evidence gathering in the case will begin.

Katherine Murray Leisure, MD, an infectious disease specialist based in Plymouth, Mass., is one of the plaintiffs. While she said that she could not comment specifically on the lawsuit, she has written publicly about her ABIM concerns in the past.

In a 2015 letter to Dr. Baron and posted on an anti-MOC website, Dr. Murray outlined a litany of complaints against ABIM’s MOC process and called on the U.S. Congress to investigate ABIM’s financial, legal, and ethical conduct.

“[The American Board of Medical Specialties] and ABIM collected more than $10,000 in fees and lost practice hours every decade from each [diplomate] doing MOC,” Dr. Murray Leisure wrote. “MOC took weeks away from our offices, clinics, patients, families, specialty societies, and individual research. ABMS MOC removed hundreds, perhaps thousands … of America’s best, once board-certified physicians from full hospital careers and earnings whenever [diplomates] did not complete these high-stakes MOC programs. … The righteous and fast solution to such moral, ethical, scientific, and constitutional problems is to end MOC now.”

Plaintiffs Glen Dela Cruz Manalo, MD; Alexa Joshua, MD; and Gerard Kenney, MD, did not return messages seeking comment. When contacted, attorneys for the plaintiffs declined to comment.

The doctors’ 32-page lawsuit characterizes ABIM as an organization motivated by money that has made its MOC process increasingly more burdensome for physicians over the years without evidence that MOC has any beneficial impact on doctors, patients, or the public. Complying with ABIM’s MOC costs internists an average of $23,607 in financial cost and time lost over 10 years, and costs up to $40,495 for some specialists, according to the suit.

The physicians allege that ABIM controls in excess of 95% of the market for MOC of internists, in violation of federal antitrust laws, and that the organization has unlawfully obtained and maintained monopoly power for MOC services.

The board’s illegal tying of its initial certification to its MOC results in burdensome conditions, including “raising the cost of the practice of medicine, constraining the supply of internists thereby harming competition, decreasing the supply of certified internists, and increasing the cost of medical services to patients and consumers,” the suit claims.

The legal challenge details how MOC has personally and professionally impacted each of the four plaintiffs. Dr. Manalo, a gastroenterologist, lost his privileges at St. Vincent Healthcare in Billings, Mont., and was subsequently terminated after he declined to maintain his ABIM certification as a gastroenterologist. In a letter to ABIM, Dr. Manalo wrote that it was “unfair and outright discriminatory that practitioners certified on or after 1990 are the only ones required to certify,” according to the lawsuit. Dr. Manalo later took a position as staff gastroenterologist at Jonathan M. Wainwright Memorial Veterans Affairs Medical Center in Walla Walla, Wash., at a substantially reduced salary. He became unemployed in 2017.

Dr. Murray Leisure obtained an initial and lifelong board certification in internal medicine from ABIM in 1984 and an infectious disease certification in 1990. ABlM terminated Dr. Murray’s infectious diseases certification after she failed her MOC examination in 2009, which led to lost privileges at Jordan Hospital in Plymouth, Mass. The loss caused significant damage to Dr. Murray, including lost income, a tarnished reputation, and the lost opportunity to help patients, according to the lawsuit. Jordan Hospital restored her privileges after Dr. Murray passed her MOC examination in 2012.

Dr. Kenney lost a job opportunity with Mount Nittany Physicians Group in State College, Pa., after he declined to renew his ABIM certification in gastroenterology. He is currently a physician with the University of Pittsburgh Medical Center in Seneca, Pa.

That the ABIM website lists him as “not certified,” is misleading, and makes it appear that his initial certifications were revoked due to failure to pass a MOC examination or misconduct, rather than because the certifications lapsed, according to the suit. The description makes Dr. Kenney appear less qualified to patients, hospitals, insurance companies, medical corporations, other employers, and others, he claims.

Dr. Joshua could not renew her consulting and admitting privileges at Detroit Medical Center after she failed an MOC examination in 2014 and became uncertified in internal medicine, according to the suit. In addition, Blue Cross Blue Shield informed Dr. Joshua it would no longer cover her because it required ABIM certification for coverage. She unsuccessfully appealed based on her certification with the National Board of Physicians and Surgeons. As a result of her certification termination, Dr. Joshua can only practice outpatient medicine at Detroit Medical Center.

In an interview, Dr. Baron emphasized the number of modifications made to its MOC process in recent years after responding to physician concerns. This includes an overhaul of the organization’s governance structure to include more than 200 practicing physicians and opening new avenues for physicians to engage in the creation of assessment content that more closely reflects what they see in practice, he said. In addition, ABIM now surveys all specialists to contribute to the exam blueprint review and the creation of the new Item Writing Task Force.

*This story was updated on Feb. 6, 2019.

A group of internists is suing the American Board of Internal Medicine over its maintenance of certification (MOC) process, alleging that the board is monopolizing the MOC market.

jsmith/iStockphoto

The lawsuit, filed Dec. 6 in Pennsylvania district court, claims that ABIM is charging inflated monopoly prices for maintaining certification, that the organization is forcing physicians to purchase MOC, and that ABIM is inducing employers and others to require ABIM certification. The four plaintiff-physicians are asking a judge to find ABIM in violation of federal antitrust law and to bar the board from continuing its MOC process. The suit is filed as a class action on behalf of all internists and subspecialists required by ABIM to purchase MOC to maintain their ABIM certifications. The plaintiffs seek damages and injunctive relief, plus lawsuit and attorney costs arising from ABIM’s alleged antitrust violations.

In a statement, ABIM expressed disappointment at the lawsuit and said the organization will vigorously defend itself, adding that doing so will “consume resources far better dedicated to continuous improvement of its programs.”

ABIM declined to answer questions addressing specific accusations from the lawsuit. However, in an interview, ABIM President Richard Baron, MD, said that “ABIM board-certified physicians have taken the initiative to distinguish themselves. This is a credential that physicians earn. We offer certified physicians the opportunity to demonstrate to the medical community, their peers, and the public that they are current and have special expertise.”

ABIM has not yet filed a formal response to the lawsuit, which was due by Jan. 6. Court documents show that in January, ABIM entered the appearances of four attorneys that will represent the board in the case. From there, discovery and evidence gathering in the case will begin.

Katherine Murray Leisure, MD, an infectious disease specialist based in Plymouth, Mass., is one of the plaintiffs. While she said that she could not comment specifically on the lawsuit, she has written publicly about her ABIM concerns in the past.

In a 2015 letter to Dr. Baron and posted on an anti-MOC website, Dr. Murray outlined a litany of complaints against ABIM’s MOC process and called on the U.S. Congress to investigate ABIM’s financial, legal, and ethical conduct.

“[The American Board of Medical Specialties] and ABIM collected more than $10,000 in fees and lost practice hours every decade from each [diplomate] doing MOC,” Dr. Murray Leisure wrote. “MOC took weeks away from our offices, clinics, patients, families, specialty societies, and individual research. ABMS MOC removed hundreds, perhaps thousands … of America’s best, once board-certified physicians from full hospital careers and earnings whenever [diplomates] did not complete these high-stakes MOC programs. … The righteous and fast solution to such moral, ethical, scientific, and constitutional problems is to end MOC now.”

Plaintiffs Glen Dela Cruz Manalo, MD; Alexa Joshua, MD; and Gerard Kenney, MD, did not return messages seeking comment. When contacted, attorneys for the plaintiffs declined to comment.

The doctors’ 32-page lawsuit characterizes ABIM as an organization motivated by money that has made its MOC process increasingly more burdensome for physicians over the years without evidence that MOC has any beneficial impact on doctors, patients, or the public. Complying with ABIM’s MOC costs internists an average of $23,607 in financial cost and time lost over 10 years, and costs up to $40,495 for some specialists, according to the suit.

The physicians allege that ABIM controls in excess of 95% of the market for MOC of internists, in violation of federal antitrust laws, and that the organization has unlawfully obtained and maintained monopoly power for MOC services.

The board’s illegal tying of its initial certification to its MOC results in burdensome conditions, including “raising the cost of the practice of medicine, constraining the supply of internists thereby harming competition, decreasing the supply of certified internists, and increasing the cost of medical services to patients and consumers,” the suit claims.

The legal challenge details how MOC has personally and professionally impacted each of the four plaintiffs. Dr. Manalo, a gastroenterologist, lost his privileges at St. Vincent Healthcare in Billings, Mont., and was subsequently terminated after he declined to maintain his ABIM certification as a gastroenterologist. In a letter to ABIM, Dr. Manalo wrote that it was “unfair and outright discriminatory that practitioners certified on or after 1990 are the only ones required to certify,” according to the lawsuit. Dr. Manalo later took a position as staff gastroenterologist at Jonathan M. Wainwright Memorial Veterans Affairs Medical Center in Walla Walla, Wash., at a substantially reduced salary. He became unemployed in 2017.

Dr. Murray Leisure obtained an initial and lifelong board certification in internal medicine from ABIM in 1984 and an infectious disease certification in 1990. ABlM terminated Dr. Murray’s infectious diseases certification after she failed her MOC examination in 2009, which led to lost privileges at Jordan Hospital in Plymouth, Mass. The loss caused significant damage to Dr. Murray, including lost income, a tarnished reputation, and the lost opportunity to help patients, according to the lawsuit. Jordan Hospital restored her privileges after Dr. Murray passed her MOC examination in 2012.

Dr. Kenney lost a job opportunity with Mount Nittany Physicians Group in State College, Pa., after he declined to renew his ABIM certification in gastroenterology. He is currently a physician with the University of Pittsburgh Medical Center in Seneca, Pa.

That the ABIM website lists him as “not certified,” is misleading, and makes it appear that his initial certifications were revoked due to failure to pass a MOC examination or misconduct, rather than because the certifications lapsed, according to the suit. The description makes Dr. Kenney appear less qualified to patients, hospitals, insurance companies, medical corporations, other employers, and others, he claims.

Dr. Joshua could not renew her consulting and admitting privileges at Detroit Medical Center after she failed an MOC examination in 2014 and became uncertified in internal medicine, according to the suit. In addition, Blue Cross Blue Shield informed Dr. Joshua it would no longer cover her because it required ABIM certification for coverage. She unsuccessfully appealed based on her certification with the National Board of Physicians and Surgeons. As a result of her certification termination, Dr. Joshua can only practice outpatient medicine at Detroit Medical Center.

In an interview, Dr. Baron emphasized the number of modifications made to its MOC process in recent years after responding to physician concerns. This includes an overhaul of the organization’s governance structure to include more than 200 practicing physicians and opening new avenues for physicians to engage in the creation of assessment content that more closely reflects what they see in practice, he said. In addition, ABIM now surveys all specialists to contribute to the exam blueprint review and the creation of the new Item Writing Task Force.

*This story was updated on Feb. 6, 2019.

BONITA SPRINGS, FLA. – Treating disorders tied to the use of highly potent synthetic opioids (HPSO), such as fentanyl, is challenging at best, an expert said at the annual meeting of the American Academy of Addiction Psychiatry.

“We have essentially no data to guide pharmacotherapy management decisions for the leading cause of fatal overdose deaths in the U.S.,” said John J. Mariani, MD, associate professor of clinical psychiatry at Columbia University, New York. “In the absence of data to make evidence-based recommendations, we still need to treat patients.”

That means taking what is known about the properties of those drugs into account when making treatment decisions, he said. Fentanyl quickly crosses the blood-brain barrier and is rapidly distributed to peripheral tissue. It has a short duration of action, but its duration can be extended with multiple injections or an infusion, he said. Research suggests that it has opioid receptor affinity similar to that of morphine, and it’s not known why it is up to 100 times more potent than morphine.

From his own experience, he offered some suggestions on treating patients who use HPSOs:

• Buprenorphine: Clinicians using buprenorphine as induction treatment have to wait longer from the last use to the first dose because of its longer effective half-life, and other medications might be needed to manage withdrawal. For maintenance, higher doses possibly should be considered to prevent HPSO override and to maintain opioid tolerance.
• Extended-release naltrexone: This involves a more difficult induction, and there is a question of whether inpatient treatment is better than outpatient, he said. For maintenance, more frequent administration should be considered, with closer monitoring for the risk of override and more urine toxicology testing.
• Methadone: For induction, methadone could offer an advantage over buprenorphine, because there is no risk of precipitated withdrawal. For maintenance, Dr. Mariani said, it’s not known whether standard doses protect against raising tolerance out of the reach of HPSOs’ effects.
• Naloxone: He said there have been increasing reports of multiple doses being needed to reverse an overdose. Because of the shorter time between substance use and death with fentanyl, more reports have been filed on unsuccessful attempts to revive people with naloxone despite multiple doses or stronger doses. Some naloxone programs have been giving more than two standard doses or using devices that give higher doses, he said. Also, since many users never intend to take fentanyl but are exposed to it through what they thought was heroin, communication is vital, he said.

Addiction psychiatrists “need to educate patients, families, and other clinicians of this new risk of using opioids,” he said.

Meanwhile, in another talk, Thomas Kosten, MD, described progress in the efforts to develop a vaccine against fentanyl addiction, in the hopes of preventing overdoses. Researchers are taking cues from the failed attempt to develop a cocaine vaccine a few years ago, in which not enough antibodies were produced in about half the patients.

BONITA SPRINGS, FLA. – Treating disorders tied to the use of highly potent synthetic opioids (HPSO), such as fentanyl, is challenging at best, an expert said at the annual meeting of the American Academy of Addiction Psychiatry.

“We have essentially no data to guide pharmacotherapy management decisions for the leading cause of fatal overdose deaths in the U.S.,” said John J. Mariani, MD, associate professor of clinical psychiatry at Columbia University, New York. “In the absence of data to make evidence-based recommendations, we still need to treat patients.”

That means taking what is known about the properties of those drugs into account when making treatment decisions, he said. Fentanyl quickly crosses the blood-brain barrier and is rapidly distributed to peripheral tissue. It has a short duration of action, but its duration can be extended with multiple injections or an infusion, he said. Research suggests that it has opioid receptor affinity similar to that of morphine, and it’s not known why it is up to 100 times more potent than morphine.

From his own experience, he offered some suggestions on treating patients who use HPSOs:

• Buprenorphine: Clinicians using buprenorphine as induction treatment have to wait longer from the last use to the first dose because of its longer effective half-life, and other medications might be needed to manage withdrawal. For maintenance, higher doses possibly should be considered to prevent HPSO override and to maintain opioid tolerance.
• Extended-release naltrexone: This involves a more difficult induction, and there is a question of whether inpatient treatment is better than outpatient, he said. For maintenance, more frequent administration should be considered, with closer monitoring for the risk of override and more urine toxicology testing.
• Methadone: For induction, methadone could offer an advantage over buprenorphine, because there is no risk of precipitated withdrawal. For maintenance, Dr. Mariani said, it’s not known whether standard doses protect against raising tolerance out of the reach of HPSOs’ effects.
• Naloxone: He said there have been increasing reports of multiple doses being needed to reverse an overdose. Because of the shorter time between substance use and death with fentanyl, more reports have been filed on unsuccessful attempts to revive people with naloxone despite multiple doses or stronger doses. Some naloxone programs have been giving more than two standard doses or using devices that give higher doses, he said. Also, since many users never intend to take fentanyl but are exposed to it through what they thought was heroin, communication is vital, he said.

Addiction psychiatrists “need to educate patients, families, and other clinicians of this new risk of using opioids,” he said.

Meanwhile, in another talk, Thomas Kosten, MD, described progress in the efforts to develop a vaccine against fentanyl addiction, in the hopes of preventing overdoses. Researchers are taking cues from the failed attempt to develop a cocaine vaccine a few years ago, in which not enough antibodies were produced in about half the patients.

BONITA SPRINGS, FLA. – Treating disorders tied to the use of highly potent synthetic opioids (HPSO), such as fentanyl, is challenging at best, an expert said at the annual meeting of the American Academy of Addiction Psychiatry.

“We have essentially no data to guide pharmacotherapy management decisions for the leading cause of fatal overdose deaths in the U.S.,” said John J. Mariani, MD, associate professor of clinical psychiatry at Columbia University, New York. “In the absence of data to make evidence-based recommendations, we still need to treat patients.”

That means taking what is known about the properties of those drugs into account when making treatment decisions, he said. Fentanyl quickly crosses the blood-brain barrier and is rapidly distributed to peripheral tissue. It has a short duration of action, but its duration can be extended with multiple injections or an infusion, he said. Research suggests that it has opioid receptor affinity similar to that of morphine, and it’s not known why it is up to 100 times more potent than morphine.

From his own experience, he offered some suggestions on treating patients who use HPSOs:

• Buprenorphine: Clinicians using buprenorphine as induction treatment have to wait longer from the last use to the first dose because of its longer effective half-life, and other medications might be needed to manage withdrawal. For maintenance, higher doses possibly should be considered to prevent HPSO override and to maintain opioid tolerance.
• Extended-release naltrexone: This involves a more difficult induction, and there is a question of whether inpatient treatment is better than outpatient, he said. For maintenance, more frequent administration should be considered, with closer monitoring for the risk of override and more urine toxicology testing.
• Methadone: For induction, methadone could offer an advantage over buprenorphine, because there is no risk of precipitated withdrawal. For maintenance, Dr. Mariani said, it’s not known whether standard doses protect against raising tolerance out of the reach of HPSOs’ effects.
• Naloxone: He said there have been increasing reports of multiple doses being needed to reverse an overdose. Because of the shorter time between substance use and death with fentanyl, more reports have been filed on unsuccessful attempts to revive people with naloxone despite multiple doses or stronger doses. Some naloxone programs have been giving more than two standard doses or using devices that give higher doses, he said. Also, since many users never intend to take fentanyl but are exposed to it through what they thought was heroin, communication is vital, he said.

Addiction psychiatrists “need to educate patients, families, and other clinicians of this new risk of using opioids,” he said.

Meanwhile, in another talk, Thomas Kosten, MD, described progress in the efforts to develop a vaccine against fentanyl addiction, in the hopes of preventing overdoses. Researchers are taking cues from the failed attempt to develop a cocaine vaccine a few years ago, in which not enough antibodies were produced in about half the patients.

It’s well known that overuse is an enormous problem in medicine, and when it comes to antibiotics, the problem is even more striking.

FotoMaximum/Thinkstock

“Half of all inpatient antibiotic use is inappropriate,” says Valerie Vaughn, MD, MSc, a hospitalist at the University of Michigan, Ann Arbor, and coauthor of a BMJ editorial about EHRs and antibiotic overuse.

“This has led to an increase in antibiotic-related adverse events (~20% of all hospitalized patients on antibiotics), Clostridium difficile infections (half a million infections and 29,000 deaths in U.S. annually), and resistant bacteria (which now account for nearly 12% of all bacterial infections, costing $2.2 billion annually).”

EHRs can be a tool to combat that trend – if they are well designed. Clinicians are influenced by the design of their electronic health record, Dr. Vaughn said. “Rather than leave its influence to chance, we should capitalize on what is known about design to promote appropriate testing and treatment through the EHR.” Hospitalists – integral to quality improvement – can have a role in making these changes.

“These improvements will be the most effective if behavioral economics and nudging are considered while designing,” Dr. Vaughn said. “For example, when creating order sets, list recommended options first and when possible make them the default,” she said. “This little change will greatly improve appropriate use.”

For every hour physicians spend on direct patient care, they spend another two with the EHR, Dr. Vaughn wrote. “Given this degree of attention, it is not surprising that the EHR influences physician behavior, especially the overuse of low-value medical care. … Displaying brand-name instead of generic options leads to more expensive prescribing. Allowing labs to be ordered recurrently increases unnecessary phlebotomy. Even individually listing inappropriate antibiotics (rather than grouping them) can make them more noticeable, resulting in more broad-spectrum use.”

“All hospitalists – and humans – are affected by knee-jerk responses. One of the most common in medicine is the urge to treat a positive culture or any positive test. Recognize this urge and resist!” she said. “Antibiotics may be the correct response, but clinicians should first think about whether treatment is necessary based on that patient’s symptoms and comorbidities. Resist the knee-jerk urge to give antibiotics for every positive culture.”
 

Reference

Vaughn VM et al. Thoughtless design of the electronic health record drives overuse, but purposeful design can nudge improved patient care. BMJ Qual Saf. 24 Mar 2018. doi: 10.1136/bmjqs-2017-007578.

It’s well known that overuse is an enormous problem in medicine, and when it comes to antibiotics, the problem is even more striking.

FotoMaximum/Thinkstock

“Half of all inpatient antibiotic use is inappropriate,” says Valerie Vaughn, MD, MSc, a hospitalist at the University of Michigan, Ann Arbor, and coauthor of a BMJ editorial about EHRs and antibiotic overuse.

“This has led to an increase in antibiotic-related adverse events (~20% of all hospitalized patients on antibiotics), Clostridium difficile infections (half a million infections and 29,000 deaths in U.S. annually), and resistant bacteria (which now account for nearly 12% of all bacterial infections, costing $2.2 billion annually).”

EHRs can be a tool to combat that trend – if they are well designed. Clinicians are influenced by the design of their electronic health record, Dr. Vaughn said. “Rather than leave its influence to chance, we should capitalize on what is known about design to promote appropriate testing and treatment through the EHR.” Hospitalists – integral to quality improvement – can have a role in making these changes.

“These improvements will be the most effective if behavioral economics and nudging are considered while designing,” Dr. Vaughn said. “For example, when creating order sets, list recommended options first and when possible make them the default,” she said. “This little change will greatly improve appropriate use.”

For every hour physicians spend on direct patient care, they spend another two with the EHR, Dr. Vaughn wrote. “Given this degree of attention, it is not surprising that the EHR influences physician behavior, especially the overuse of low-value medical care. … Displaying brand-name instead of generic options leads to more expensive prescribing. Allowing labs to be ordered recurrently increases unnecessary phlebotomy. Even individually listing inappropriate antibiotics (rather than grouping them) can make them more noticeable, resulting in more broad-spectrum use.”

“All hospitalists – and humans – are affected by knee-jerk responses. One of the most common in medicine is the urge to treat a positive culture or any positive test. Recognize this urge and resist!” she said. “Antibiotics may be the correct response, but clinicians should first think about whether treatment is necessary based on that patient’s symptoms and comorbidities. Resist the knee-jerk urge to give antibiotics for every positive culture.”
 

Reference

Vaughn VM et al. Thoughtless design of the electronic health record drives overuse, but purposeful design can nudge improved patient care. BMJ Qual Saf. 24 Mar 2018. doi: 10.1136/bmjqs-2017-007578.

It’s well known that overuse is an enormous problem in medicine, and when it comes to antibiotics, the problem is even more striking.

FotoMaximum/Thinkstock

“Half of all inpatient antibiotic use is inappropriate,” says Valerie Vaughn, MD, MSc, a hospitalist at the University of Michigan, Ann Arbor, and coauthor of a BMJ editorial about EHRs and antibiotic overuse.

“This has led to an increase in antibiotic-related adverse events (~20% of all hospitalized patients on antibiotics), Clostridium difficile infections (half a million infections and 29,000 deaths in U.S. annually), and resistant bacteria (which now account for nearly 12% of all bacterial infections, costing $2.2 billion annually).”

EHRs can be a tool to combat that trend – if they are well designed. Clinicians are influenced by the design of their electronic health record, Dr. Vaughn said. “Rather than leave its influence to chance, we should capitalize on what is known about design to promote appropriate testing and treatment through the EHR.” Hospitalists – integral to quality improvement – can have a role in making these changes.

“These improvements will be the most effective if behavioral economics and nudging are considered while designing,” Dr. Vaughn said. “For example, when creating order sets, list recommended options first and when possible make them the default,” she said. “This little change will greatly improve appropriate use.”

For every hour physicians spend on direct patient care, they spend another two with the EHR, Dr. Vaughn wrote. “Given this degree of attention, it is not surprising that the EHR influences physician behavior, especially the overuse of low-value medical care. … Displaying brand-name instead of generic options leads to more expensive prescribing. Allowing labs to be ordered recurrently increases unnecessary phlebotomy. Even individually listing inappropriate antibiotics (rather than grouping them) can make them more noticeable, resulting in more broad-spectrum use.”

“All hospitalists – and humans – are affected by knee-jerk responses. One of the most common in medicine is the urge to treat a positive culture or any positive test. Recognize this urge and resist!” she said. “Antibiotics may be the correct response, but clinicians should first think about whether treatment is necessary based on that patient’s symptoms and comorbidities. Resist the knee-jerk urge to give antibiotics for every positive culture.”
 

Reference

Vaughn VM et al. Thoughtless design of the electronic health record drives overuse, but purposeful design can nudge improved patient care. BMJ Qual Saf. 24 Mar 2018. doi: 10.1136/bmjqs-2017-007578.

BONITA SPRINGS, FLA. – Urine drug screening is a vital part of clinical care, but many clinicians say they do not know enough about how the tests work, an expert said at the annual meeting of the American Academy of Addiction Psychiatry.

Rebecca Ann Payne, MD, said clinicians, including residents, tend to cite little training as a reason for their uncertainty about how to interpret urine drug screen results. Also, primary care clinicians say they need more education on implementing and interpreting the screens.

The good news is that medicine and pediatric residents said they felt that a 30-minute educational program significantly boosted their knowledge base and comfort in interpreting urine drug screens, said Dr. Payne, assistant professor of neuropsychiatry and behavioral science at Palmetto Health–University of South Carolina Medical Group. She offered several points that addiction psychiatrists should be aware of:

• Be careful not to put too much stock in the results.

“A positive test doesn’t necessarily mean there’s a substance use disorder,” she said. “You still need to walk through those criteria with your patients. And a positive test doesn’t mean they’re physically dependent upon it.” She said she sometimes hears from patients who say that they’d been on a certain treatment – then failed a test given by their clinician – and had their treatment stripped away.

“Drug testing is meant to be a source of information and should not dictate treatment,” she said. “I have found it’s not unusual to hear from the community that decisions are being made solely on the results of these tests, which can be problematic.”

• Point-of-care tests, which sometimes can be bought in drug stores, she said, are “much less than perfect.”

The false-positive rate for benzodiazepines has been found to be 61%; and for methadone, it is 46%; for opioids, 22%; and for amphetamines, 21%.

• Know what your lab is actually testing for, because “it’s not universal.”

She emphasized knowing the particulars of opiate testing.

“A lot of times in a hospital setting, your lab is really only testing those opiates that are directly derived from the poppy – we’re talking about things like codeine, heroin, morphine. They’re not testing for things like your semi-synthetics or your full-synthetic opiates.”

• Know the answer to the question: “Can you get a positive result on a marijuana drug screen just from passive inhalation?”

Physicians often will be confronted by patients who insist they were only in the car or in the same room with someone who was smoking marijuana. How likely is it that their test could be positive?

“Possible,” she said, “but not probable.”

Dr. Payne’s key interest areas include teaching medical students and residents, treating substance use and psychiatric disorders that are comorbid, and conducting research in addiction psychiatry.

BONITA SPRINGS, FLA. – Urine drug screening is a vital part of clinical care, but many clinicians say they do not know enough about how the tests work, an expert said at the annual meeting of the American Academy of Addiction Psychiatry.

Rebecca Ann Payne, MD, said clinicians, including residents, tend to cite little training as a reason for their uncertainty about how to interpret urine drug screen results. Also, primary care clinicians say they need more education on implementing and interpreting the screens.

The good news is that medicine and pediatric residents said they felt that a 30-minute educational program significantly boosted their knowledge base and comfort in interpreting urine drug screens, said Dr. Payne, assistant professor of neuropsychiatry and behavioral science at Palmetto Health–University of South Carolina Medical Group. She offered several points that addiction psychiatrists should be aware of:

• Be careful not to put too much stock in the results.

“A positive test doesn’t necessarily mean there’s a substance use disorder,” she said. “You still need to walk through those criteria with your patients. And a positive test doesn’t mean they’re physically dependent upon it.” She said she sometimes hears from patients who say that they’d been on a certain treatment – then failed a test given by their clinician – and had their treatment stripped away.

“Drug testing is meant to be a source of information and should not dictate treatment,” she said. “I have found it’s not unusual to hear from the community that decisions are being made solely on the results of these tests, which can be problematic.”

• Point-of-care tests, which sometimes can be bought in drug stores, she said, are “much less than perfect.”

The false-positive rate for benzodiazepines has been found to be 61%; and for methadone, it is 46%; for opioids, 22%; and for amphetamines, 21%.

• Know what your lab is actually testing for, because “it’s not universal.”

She emphasized knowing the particulars of opiate testing.

“A lot of times in a hospital setting, your lab is really only testing those opiates that are directly derived from the poppy – we’re talking about things like codeine, heroin, morphine. They’re not testing for things like your semi-synthetics or your full-synthetic opiates.”

• Know the answer to the question: “Can you get a positive result on a marijuana drug screen just from passive inhalation?”

Physicians often will be confronted by patients who insist they were only in the car or in the same room with someone who was smoking marijuana. How likely is it that their test could be positive?

“Possible,” she said, “but not probable.”

Dr. Payne’s key interest areas include teaching medical students and residents, treating substance use and psychiatric disorders that are comorbid, and conducting research in addiction psychiatry.

BONITA SPRINGS, FLA. – Urine drug screening is a vital part of clinical care, but many clinicians say they do not know enough about how the tests work, an expert said at the annual meeting of the American Academy of Addiction Psychiatry.

Rebecca Ann Payne, MD, said clinicians, including residents, tend to cite little training as a reason for their uncertainty about how to interpret urine drug screen results. Also, primary care clinicians say they need more education on implementing and interpreting the screens.

The good news is that medicine and pediatric residents said they felt that a 30-minute educational program significantly boosted their knowledge base and comfort in interpreting urine drug screens, said Dr. Payne, assistant professor of neuropsychiatry and behavioral science at Palmetto Health–University of South Carolina Medical Group. She offered several points that addiction psychiatrists should be aware of:

• Be careful not to put too much stock in the results.

“A positive test doesn’t necessarily mean there’s a substance use disorder,” she said. “You still need to walk through those criteria with your patients. And a positive test doesn’t mean they’re physically dependent upon it.” She said she sometimes hears from patients who say that they’d been on a certain treatment – then failed a test given by their clinician – and had their treatment stripped away.

“Drug testing is meant to be a source of information and should not dictate treatment,” she said. “I have found it’s not unusual to hear from the community that decisions are being made solely on the results of these tests, which can be problematic.”

• Point-of-care tests, which sometimes can be bought in drug stores, she said, are “much less than perfect.”

The false-positive rate for benzodiazepines has been found to be 61%; and for methadone, it is 46%; for opioids, 22%; and for amphetamines, 21%.

• Know what your lab is actually testing for, because “it’s not universal.”

She emphasized knowing the particulars of opiate testing.

“A lot of times in a hospital setting, your lab is really only testing those opiates that are directly derived from the poppy – we’re talking about things like codeine, heroin, morphine. They’re not testing for things like your semi-synthetics or your full-synthetic opiates.”

• Know the answer to the question: “Can you get a positive result on a marijuana drug screen just from passive inhalation?”

Physicians often will be confronted by patients who insist they were only in the car or in the same room with someone who was smoking marijuana. How likely is it that their test could be positive?

“Possible,” she said, “but not probable.”

Dr. Payne’s key interest areas include teaching medical students and residents, treating substance use and psychiatric disorders that are comorbid, and conducting research in addiction psychiatry.

The symptoms of burnout include emotional exhaustion, depersonalization, and reduced personal efficacy, and burnout is a widespread problem among hospitalists; recent data suggest that half of physicians are experiencing at least one such symptom.

Health care leaders are increasingly concerned that these levels of physician burnout pose a threat to patient quality and safety. “As a result, some health care systems are shifting emphasis from the Triple Aim – population health, reduced costs, and patient satisfaction – to the Quadruple Aim, which incorporates health care provider wellness,” according to a recent abstract.

The authors began their own attempt to address the problem when Penn State Health in Dauphin County, Pa., built a stand-alone children’s hospital and experienced bed demands that exceeded bed availability, creating decreased organizational efficiency, high stress, and elevated physician burnout.

The LEAN principles offer a process-focused, customer-centered methodology that improves efficiency and quality. “We redesigned our service line using LEAN principles, such as ‘staff to demand’ and ‘standardize work,’ ” the authors wrote. “To ‘staff to demand,’ we hired three additional FTE [full-time equivalent employees]. This allowed creation of two rounding teams ([up] from one) and reduced our patient-to-attending ratio from 15:1 to 8:1. Workflow was resequenced and standardized, which enabled teams to see discharges at the start of rounds. We also provided in-house evening and overnight resident supervision. Our model permitted flexibility in physicians’ schedules, deemphasized reliance on RVUs, and heightened purpose and efficiency in work as determinants of providers’ value-adding capacity.”

As a result, both service line and hospital efficiency improved and faculty stress decreased in their hospital. “Mean stress scores decreased from 23 (preintervention) to 15 over the first 2 years, and has remained steady for a period of 3 years. Our divisional work-life balance measurement 2 years after the intervention was 85%, well above the reported average of 41%. We have maintained a low physician turnover rate at 3.5% over the last 3 years.”
 

Reference

Keefer L et al. LEAN in: Our secrets to decreasing provider stress, maximizing efficiency on a pediatric hospitalist service [abstract]. Accessed April 6, 2018.


 

The symptoms of burnout include emotional exhaustion, depersonalization, and reduced personal efficacy, and burnout is a widespread problem among hospitalists; recent data suggest that half of physicians are experiencing at least one such symptom.

Health care leaders are increasingly concerned that these levels of physician burnout pose a threat to patient quality and safety. “As a result, some health care systems are shifting emphasis from the Triple Aim – population health, reduced costs, and patient satisfaction – to the Quadruple Aim, which incorporates health care provider wellness,” according to a recent abstract.

The authors began their own attempt to address the problem when Penn State Health in Dauphin County, Pa., built a stand-alone children’s hospital and experienced bed demands that exceeded bed availability, creating decreased organizational efficiency, high stress, and elevated physician burnout.

The LEAN principles offer a process-focused, customer-centered methodology that improves efficiency and quality. “We redesigned our service line using LEAN principles, such as ‘staff to demand’ and ‘standardize work,’ ” the authors wrote. “To ‘staff to demand,’ we hired three additional FTE [full-time equivalent employees]. This allowed creation of two rounding teams ([up] from one) and reduced our patient-to-attending ratio from 15:1 to 8:1. Workflow was resequenced and standardized, which enabled teams to see discharges at the start of rounds. We also provided in-house evening and overnight resident supervision. Our model permitted flexibility in physicians’ schedules, deemphasized reliance on RVUs, and heightened purpose and efficiency in work as determinants of providers’ value-adding capacity.”

As a result, both service line and hospital efficiency improved and faculty stress decreased in their hospital. “Mean stress scores decreased from 23 (preintervention) to 15 over the first 2 years, and has remained steady for a period of 3 years. Our divisional work-life balance measurement 2 years after the intervention was 85%, well above the reported average of 41%. We have maintained a low physician turnover rate at 3.5% over the last 3 years.”
 

Reference

Keefer L et al. LEAN in: Our secrets to decreasing provider stress, maximizing efficiency on a pediatric hospitalist service [abstract]. Accessed April 6, 2018.


 

The symptoms of burnout include emotional exhaustion, depersonalization, and reduced personal efficacy, and burnout is a widespread problem among hospitalists; recent data suggest that half of physicians are experiencing at least one such symptom.

Health care leaders are increasingly concerned that these levels of physician burnout pose a threat to patient quality and safety. “As a result, some health care systems are shifting emphasis from the Triple Aim – population health, reduced costs, and patient satisfaction – to the Quadruple Aim, which incorporates health care provider wellness,” according to a recent abstract.

The authors began their own attempt to address the problem when Penn State Health in Dauphin County, Pa., built a stand-alone children’s hospital and experienced bed demands that exceeded bed availability, creating decreased organizational efficiency, high stress, and elevated physician burnout.

The LEAN principles offer a process-focused, customer-centered methodology that improves efficiency and quality. “We redesigned our service line using LEAN principles, such as ‘staff to demand’ and ‘standardize work,’ ” the authors wrote. “To ‘staff to demand,’ we hired three additional FTE [full-time equivalent employees]. This allowed creation of two rounding teams ([up] from one) and reduced our patient-to-attending ratio from 15:1 to 8:1. Workflow was resequenced and standardized, which enabled teams to see discharges at the start of rounds. We also provided in-house evening and overnight resident supervision. Our model permitted flexibility in physicians’ schedules, deemphasized reliance on RVUs, and heightened purpose and efficiency in work as determinants of providers’ value-adding capacity.”

As a result, both service line and hospital efficiency improved and faculty stress decreased in their hospital. “Mean stress scores decreased from 23 (preintervention) to 15 over the first 2 years, and has remained steady for a period of 3 years. Our divisional work-life balance measurement 2 years after the intervention was 85%, well above the reported average of 41%. We have maintained a low physician turnover rate at 3.5% over the last 3 years.”
 

Reference

Keefer L et al. LEAN in: Our secrets to decreasing provider stress, maximizing efficiency on a pediatric hospitalist service [abstract]. Accessed April 6, 2018.