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High-dose opioid prescribing linked to heroin use risk among U.S. veterans
SAN DIEGO – High-dose opioid prescribing is associated with an increased risk of heroin use among U.S. veterans, a prospective study showed.
“Despite evidence linking increased risk of opioid use disorder with specific opioid prescribing patterns, the relationship between these practices and heroin use is less understood,” researchers led by Geetanjoli Banerjee wrote in an abstract presented during the annual meeting of the College on Problems of Drug Dependence. “Understanding the relationship between prescription opioid use and initiation of heroin use among veterans is particularly important, as this population has both a higher underlying prevalence of substance abuse disorders and pain conditions.”
Ms. Banerjee, a graduate student at Brown University, Providence, R.I., and her associates examined data from 3,570 individuals enrolled in the Veterans Aging Cohort Study without nonmedical use or prescription opioids or heroin use in the year prior to baseline, and who received more than one prescription opioid from the VA during follow-up. between 2002 and 2012.
Among the 3,833 eligible participants, the proportion who were prescribed high-dose opioids (defined as a morphine equivalent daily dose of 90 mg or greater) did not change significantly between 2002 and 2012, and ranged from 4.4% to 5.9% (P = .22). The researchers also found that the 10-year incidence rate of recent heroin use was 8.15 event per 1,000 person-years. The time to recent heroin use differed significantly between participants with and without prior receipt of a high-dose prescription at baseline (P less than .001). Multivariable Cox regression analysis showed that prior receipt of a high-dose opioid prescription was associated with recent heroin use (adjusted hazard ratio, 2.54).
“Among patients who report no past year illicit use of opioids at baseline and who are receiving prescription opioids from the VA, receipt of high-dose prescription opioid increased the risk of subsequent heroin use,” the researchers concluded. “Patients receiving high-dose opioids, ages 50-56, with a history of HCV infection, injecting, opioid use disorder, or recent stimulant use should be screened for heroin use.”
They acknowledged certain limitations of the study, including its self-reported design and the fact that VA pharmacy data do not capture opioid prescriptions filled outside of the VA.
The study was funded by the National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse. Ms. Banerjee reported having no financial disclosures.
SAN DIEGO – High-dose opioid prescribing is associated with an increased risk of heroin use among U.S. veterans, a prospective study showed.
“Despite evidence linking increased risk of opioid use disorder with specific opioid prescribing patterns, the relationship between these practices and heroin use is less understood,” researchers led by Geetanjoli Banerjee wrote in an abstract presented during the annual meeting of the College on Problems of Drug Dependence. “Understanding the relationship between prescription opioid use and initiation of heroin use among veterans is particularly important, as this population has both a higher underlying prevalence of substance abuse disorders and pain conditions.”
Ms. Banerjee, a graduate student at Brown University, Providence, R.I., and her associates examined data from 3,570 individuals enrolled in the Veterans Aging Cohort Study without nonmedical use or prescription opioids or heroin use in the year prior to baseline, and who received more than one prescription opioid from the VA during follow-up. between 2002 and 2012.
Among the 3,833 eligible participants, the proportion who were prescribed high-dose opioids (defined as a morphine equivalent daily dose of 90 mg or greater) did not change significantly between 2002 and 2012, and ranged from 4.4% to 5.9% (P = .22). The researchers also found that the 10-year incidence rate of recent heroin use was 8.15 event per 1,000 person-years. The time to recent heroin use differed significantly between participants with and without prior receipt of a high-dose prescription at baseline (P less than .001). Multivariable Cox regression analysis showed that prior receipt of a high-dose opioid prescription was associated with recent heroin use (adjusted hazard ratio, 2.54).
“Among patients who report no past year illicit use of opioids at baseline and who are receiving prescription opioids from the VA, receipt of high-dose prescription opioid increased the risk of subsequent heroin use,” the researchers concluded. “Patients receiving high-dose opioids, ages 50-56, with a history of HCV infection, injecting, opioid use disorder, or recent stimulant use should be screened for heroin use.”
They acknowledged certain limitations of the study, including its self-reported design and the fact that VA pharmacy data do not capture opioid prescriptions filled outside of the VA.
The study was funded by the National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse. Ms. Banerjee reported having no financial disclosures.
SAN DIEGO – High-dose opioid prescribing is associated with an increased risk of heroin use among U.S. veterans, a prospective study showed.
“Despite evidence linking increased risk of opioid use disorder with specific opioid prescribing patterns, the relationship between these practices and heroin use is less understood,” researchers led by Geetanjoli Banerjee wrote in an abstract presented during the annual meeting of the College on Problems of Drug Dependence. “Understanding the relationship between prescription opioid use and initiation of heroin use among veterans is particularly important, as this population has both a higher underlying prevalence of substance abuse disorders and pain conditions.”
Ms. Banerjee, a graduate student at Brown University, Providence, R.I., and her associates examined data from 3,570 individuals enrolled in the Veterans Aging Cohort Study without nonmedical use or prescription opioids or heroin use in the year prior to baseline, and who received more than one prescription opioid from the VA during follow-up. between 2002 and 2012.
Among the 3,833 eligible participants, the proportion who were prescribed high-dose opioids (defined as a morphine equivalent daily dose of 90 mg or greater) did not change significantly between 2002 and 2012, and ranged from 4.4% to 5.9% (P = .22). The researchers also found that the 10-year incidence rate of recent heroin use was 8.15 event per 1,000 person-years. The time to recent heroin use differed significantly between participants with and without prior receipt of a high-dose prescription at baseline (P less than .001). Multivariable Cox regression analysis showed that prior receipt of a high-dose opioid prescription was associated with recent heroin use (adjusted hazard ratio, 2.54).
“Among patients who report no past year illicit use of opioids at baseline and who are receiving prescription opioids from the VA, receipt of high-dose prescription opioid increased the risk of subsequent heroin use,” the researchers concluded. “Patients receiving high-dose opioids, ages 50-56, with a history of HCV infection, injecting, opioid use disorder, or recent stimulant use should be screened for heroin use.”
They acknowledged certain limitations of the study, including its self-reported design and the fact that VA pharmacy data do not capture opioid prescriptions filled outside of the VA.
The study was funded by the National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse. Ms. Banerjee reported having no financial disclosures.
REPORTING CPDD 2018
Key clinical point: Screen patients who receive high-dose opioids and meet several other criteria for heroin use.
Major finding:. On multivariate Cox regression, prior prescription of high-dose opioids was an independent predictor of recent heroin use (adjusted hazard ratio, 2.54).
Study details: A prospective analysis of 3,833 participants in the Veterans Aging Cohort Study.
Disclosures: The study was funded by the National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse. Ms. Banerjee reported having no financial disclosures.
USPSTF: Don’t add ECG for cardio risk assessment
Adding electrocardiography screening to standard cardiovascular disease assessment is not necessary for asymptomatic, low-risk adults, according to final recommendations from the U.S. Preventive Services Task Force.
In the statement published June 12 in JAMA, the USPSTF gave a D recommendation against using ECG screening to evaluate cardiovascular disease risk in asymptomatic, low-risk individuals and issued a statement that current evidence is inadequate (I statement) to evaluate the harms versus benefits of additional ECG for asymptomatic individuals who may be at medium to high risk for future cardiovascular events.
The Task Force concluded that the potential harms of screening ECG outweigh or equal potential benefits in the asymptomatic low-risk population. However, they noted clinical considerations for screening in moderate to high-risk individuals including the potential for more intensive medical management in those identified as higher risk after an ECG, balanced by the potential for harms from medication side effects or follow-up procedures.
Treatment for asymptomatic adults at increased risk for CVD may include lipid-lowering medications, tobacco cessation, and lifestyle modifications regarding diet and exercise, according to the Task Force, and guidelines already exist for many of these factors.
ECG screening could reclassify individuals as higher or lower risk, which could potentially improve health outcomes, wrote Daniel E. Jonas, MD, of the University of North Carolina, Chapel Hill, and his colleagues in the evidence report accompanying the recommendations. The researchers reviewed data from 16 studies including 77,140 individuals. However, the strength of evidence was low for the value of ECG to reclassify individuals, and no improvements in health outcomes were noted, even in high-risk populations such as diabetes patients, the researchers said.
In particular, no significant improvement from additional exercise ECG occurred in a pair of randomized controlled trials including 1,151 individuals, they noted.
The final recommendation reflects the 2017 draft statement and the 2012 final recommendation statement. The full recommendation statement is available online in JAMA and on the Task Force website.
The research was funded by the Agency for Healthcare Research and Quality under a grant from the U.S. Department of Health and Human Services. The researchers had no financial conflicts to disclose.
SOURCES: Jonas D et al. JAMA. 2018 Jun 12;319(22):2315-28; Curry S et al. JAMA. 2018 Jun 12;319(22):2308-14.
The conclusions reached by the USPSTF were warranted, based on the latest research, but may be modified by future information as the science evolves.
In contrast to the 2004 and 2012 task force statements, which were focused on coronary heart disease events, the current analysis used a measure of cardiovascular events, defined as the composite of coronary heart disease, cerebrovascular disease, and peripheral artery disease. Given that ECG parameters usually reflect the presence of coronary heart disease, their value as a predictor of cardiovascular disease in asymptomatic adults may be limited.
The evidence reviewed by the USPSTF shows that ECG screening of low-risk individuals is unlikely to prevent CVD; however, the assessment of risk remains a challenge and puts the decision on physicians based on individual risk factors. It would be an overstatement of current knowledge to conclude that patients at the higher end of the intermediate to high-risk classification would benefit from routine ECG testing with repeated measures over time,” he said.
However, risk factors aside, one special population to be considered for ECG screening is competitive athletes. Screening athletes is common in many countries, though somewhat controversial in the United States, despite its increasing use by professional and college sports team. More research is needed on the value of resting and exercise ECG as markers of CVD risk, and new data may lead researchers to reassess the value of ECG procedures and use them for improved risk classification.
Robert J. Myerburg, MD, an electrophysiologist at the University of Miami, made these comments in an editorial accompanying the article (JAMA. 2018 June 12;319[2]:2277-9). He had no financial conflicts to disclose.
The conclusions reached by the USPSTF were warranted, based on the latest research, but may be modified by future information as the science evolves.
In contrast to the 2004 and 2012 task force statements, which were focused on coronary heart disease events, the current analysis used a measure of cardiovascular events, defined as the composite of coronary heart disease, cerebrovascular disease, and peripheral artery disease. Given that ECG parameters usually reflect the presence of coronary heart disease, their value as a predictor of cardiovascular disease in asymptomatic adults may be limited.
The evidence reviewed by the USPSTF shows that ECG screening of low-risk individuals is unlikely to prevent CVD; however, the assessment of risk remains a challenge and puts the decision on physicians based on individual risk factors. It would be an overstatement of current knowledge to conclude that patients at the higher end of the intermediate to high-risk classification would benefit from routine ECG testing with repeated measures over time,” he said.
However, risk factors aside, one special population to be considered for ECG screening is competitive athletes. Screening athletes is common in many countries, though somewhat controversial in the United States, despite its increasing use by professional and college sports team. More research is needed on the value of resting and exercise ECG as markers of CVD risk, and new data may lead researchers to reassess the value of ECG procedures and use them for improved risk classification.
Robert J. Myerburg, MD, an electrophysiologist at the University of Miami, made these comments in an editorial accompanying the article (JAMA. 2018 June 12;319[2]:2277-9). He had no financial conflicts to disclose.
The conclusions reached by the USPSTF were warranted, based on the latest research, but may be modified by future information as the science evolves.
In contrast to the 2004 and 2012 task force statements, which were focused on coronary heart disease events, the current analysis used a measure of cardiovascular events, defined as the composite of coronary heart disease, cerebrovascular disease, and peripheral artery disease. Given that ECG parameters usually reflect the presence of coronary heart disease, their value as a predictor of cardiovascular disease in asymptomatic adults may be limited.
The evidence reviewed by the USPSTF shows that ECG screening of low-risk individuals is unlikely to prevent CVD; however, the assessment of risk remains a challenge and puts the decision on physicians based on individual risk factors. It would be an overstatement of current knowledge to conclude that patients at the higher end of the intermediate to high-risk classification would benefit from routine ECG testing with repeated measures over time,” he said.
However, risk factors aside, one special population to be considered for ECG screening is competitive athletes. Screening athletes is common in many countries, though somewhat controversial in the United States, despite its increasing use by professional and college sports team. More research is needed on the value of resting and exercise ECG as markers of CVD risk, and new data may lead researchers to reassess the value of ECG procedures and use them for improved risk classification.
Robert J. Myerburg, MD, an electrophysiologist at the University of Miami, made these comments in an editorial accompanying the article (JAMA. 2018 June 12;319[2]:2277-9). He had no financial conflicts to disclose.
Adding electrocardiography screening to standard cardiovascular disease assessment is not necessary for asymptomatic, low-risk adults, according to final recommendations from the U.S. Preventive Services Task Force.
In the statement published June 12 in JAMA, the USPSTF gave a D recommendation against using ECG screening to evaluate cardiovascular disease risk in asymptomatic, low-risk individuals and issued a statement that current evidence is inadequate (I statement) to evaluate the harms versus benefits of additional ECG for asymptomatic individuals who may be at medium to high risk for future cardiovascular events.
The Task Force concluded that the potential harms of screening ECG outweigh or equal potential benefits in the asymptomatic low-risk population. However, they noted clinical considerations for screening in moderate to high-risk individuals including the potential for more intensive medical management in those identified as higher risk after an ECG, balanced by the potential for harms from medication side effects or follow-up procedures.
Treatment for asymptomatic adults at increased risk for CVD may include lipid-lowering medications, tobacco cessation, and lifestyle modifications regarding diet and exercise, according to the Task Force, and guidelines already exist for many of these factors.
ECG screening could reclassify individuals as higher or lower risk, which could potentially improve health outcomes, wrote Daniel E. Jonas, MD, of the University of North Carolina, Chapel Hill, and his colleagues in the evidence report accompanying the recommendations. The researchers reviewed data from 16 studies including 77,140 individuals. However, the strength of evidence was low for the value of ECG to reclassify individuals, and no improvements in health outcomes were noted, even in high-risk populations such as diabetes patients, the researchers said.
In particular, no significant improvement from additional exercise ECG occurred in a pair of randomized controlled trials including 1,151 individuals, they noted.
The final recommendation reflects the 2017 draft statement and the 2012 final recommendation statement. The full recommendation statement is available online in JAMA and on the Task Force website.
The research was funded by the Agency for Healthcare Research and Quality under a grant from the U.S. Department of Health and Human Services. The researchers had no financial conflicts to disclose.
SOURCES: Jonas D et al. JAMA. 2018 Jun 12;319(22):2315-28; Curry S et al. JAMA. 2018 Jun 12;319(22):2308-14.
Adding electrocardiography screening to standard cardiovascular disease assessment is not necessary for asymptomatic, low-risk adults, according to final recommendations from the U.S. Preventive Services Task Force.
In the statement published June 12 in JAMA, the USPSTF gave a D recommendation against using ECG screening to evaluate cardiovascular disease risk in asymptomatic, low-risk individuals and issued a statement that current evidence is inadequate (I statement) to evaluate the harms versus benefits of additional ECG for asymptomatic individuals who may be at medium to high risk for future cardiovascular events.
The Task Force concluded that the potential harms of screening ECG outweigh or equal potential benefits in the asymptomatic low-risk population. However, they noted clinical considerations for screening in moderate to high-risk individuals including the potential for more intensive medical management in those identified as higher risk after an ECG, balanced by the potential for harms from medication side effects or follow-up procedures.
Treatment for asymptomatic adults at increased risk for CVD may include lipid-lowering medications, tobacco cessation, and lifestyle modifications regarding diet and exercise, according to the Task Force, and guidelines already exist for many of these factors.
ECG screening could reclassify individuals as higher or lower risk, which could potentially improve health outcomes, wrote Daniel E. Jonas, MD, of the University of North Carolina, Chapel Hill, and his colleagues in the evidence report accompanying the recommendations. The researchers reviewed data from 16 studies including 77,140 individuals. However, the strength of evidence was low for the value of ECG to reclassify individuals, and no improvements in health outcomes were noted, even in high-risk populations such as diabetes patients, the researchers said.
In particular, no significant improvement from additional exercise ECG occurred in a pair of randomized controlled trials including 1,151 individuals, they noted.
The final recommendation reflects the 2017 draft statement and the 2012 final recommendation statement. The full recommendation statement is available online in JAMA and on the Task Force website.
The research was funded by the Agency for Healthcare Research and Quality under a grant from the U.S. Department of Health and Human Services. The researchers had no financial conflicts to disclose.
SOURCES: Jonas D et al. JAMA. 2018 Jun 12;319(22):2315-28; Curry S et al. JAMA. 2018 Jun 12;319(22):2308-14.
FROM JAMA
Key clinical point:
Major finding: Two randomized controlled trials including 1,151 individuals found no significant improvement from additional exercise ECG.
Study details: Researchers reviewed data from 16 studies including 77,140 individuals.
Disclosures: The research was funded by the Agency for Healthcare Research and Quality under a grant from the U.S. Department of Health & Human Services. The researchers had no financial conflicts to disclose.
Sources: Jonas D et al. JAMA.2018;319[22]:2315-28; Curry S et al. JAMA.2018;319[22]:2308-14.
DOAC’s edge over warfarin fades with low adherence
BOSTON – The direct acting oral anticoagulants boost patient adherence compared with warfarin anticoagulation, but when patients did not adhere to their regimens, those prescribed a new, direct-acting oral anticoagulant had worse outcomes than did patients on warfarin – even patients poorly adherent with warfarin – based on data from more than 80,000 U.S. patients.
Among low-adherence patients, defined as those with adherence rates of 40%-80% based on prescriptions filled, patients with nonvalvular atrial fibrillation and a CHA2DS2-VASc score of at least 2 and treated with warfarin had a 3.37/100 patient-years rate of thromboembolic events–driven hospitalizations or emergency department visits, compared with a 4.05/100 patient-years rate among low-adherence patients receiving a direct-acting oral anticoagulant (DOAC), Dhanunjaya Lakkireddy, MD, said at the annual scientific sessions of the Heart Rhythm Society. The incidence of strokes of any kind was also lower in the low-adherence warfarin patients compared with the low-adherence DOAC patients, although the relationship flipped for hemorrhagic strokes and bleeds, which were more common in the warfarin patients.
In contrast, when patients were adherent, taking more than 80% of their prescribed drug, the performance of the DOACs generally surpassed that of warfarin. In an analysis adjusted for several demographic and clinical confounders, and when compared with patients adherent to a warfarin regimen, those adherent to a DOAC had a 7% lower rate of thromboembolic events, a 36% lower rate of hemorrhagic strokes, an 8% lower rate of any stroke, and a 10% lower rate of bleeds (excluding hemorrhagic strokes), all statistically significant differences, reported Dr. Lakkireddy, medical director of the Kansas City Heart Rhythm Institute in Overland Park, Kan.
The message from this analysis is the importance of maximizing patient adherence, Dr. Lakkireddy said.
“We should not make the false assumption that putting a patient on a DOAC will take care of everything. We need to make it a habit to make sure patients are taking their pills,” he said in an interview. “We were surprised. Our assumption was that the DOACs were more forgiving than warfarin” in poorly compliant patients. “We need to make talking about adherence with patients routine.”
The results also documented that adherence to therapy is better with a DOAC, with a 74% rate of good adherence among the nearly 41,000 patients in the database prescribed a DOAC compared with a 63% rate of good compliance among the more than 42,000 patients prescribed warfarin.
“It’s ironic that we might think low-adherence patients should go on warfarin. That’s sort of backwards,” said Andrew D. Krahn, MD, a cardiac electrophysiologist and professor of medicine at the University of British Columbia in Vancouver. “It’s not biologically plausible” to predict that less adherent patients would do better on warfarin, he noted.
The study run by Dr. Lakkireddy and his associates used data collected by IBM Watson Health Market Scan from about 4 million Medicare patients and 47 million American residents with private insurance during 2012-2016. They focused on the more than 600,000 patients prescribed an anticoagulant during 2014 and 2015, and then narrowed the study group down to just over 83,000 adults with nonvalvular atrial fibrillation, a CHA2DS2-VASc score of 2 or more. The patients’ average age was about 74 years.
Dr. Lakkireddy has been a consultant to or has received research support from Biosense Webster, Boehringer Ingelheim, Bristol Myers Squibb, EstechPharma, Janssen, Pfizer, SentreHeart, and St. Jude. Dr. Krahn has been a consultant to Medtronic and has received research support from Medtronic and Boston Scientific.
SOURCE: Lakkireddy D et al. Heart Rhythm 2018, Abstract B-LBCT02-03.
What is clear from this analysis is that adherence to oral anticoagulant regimens is something we need to address. It would help if we could determine why patients are not well adherent, but regardless of the cause, changing patient behavior and improving adherence will require better patient education and better integration of medical care toward better adherence.
This study has several obvious limitations, including its reliance on an administrative database that does not allow for adjudication of outcomes. The analysis presented so far is also limited by not breaking down the direct-acting oral anticoagulant into individual drugs, and without propensity-score matching of the two treatment subgroups.
We must be very alert to the possibility for confounding by indication in a real-world dataset like this. For example, the stroke rate we see in the patients treated with a DOAC may be affected by clinicians who preferentially prescribed one of the direct-acting drugs to patients who had what they thought was a high stroke risk because they felt these drugs might work better for stroke prevention than warfarin.
What is also notable in the results is that, even among the patients with good adherence, the event and adverse effects rates remained high. Among the highly adherent patients the thromboembolic event rate was greater than 3% per year in both the warfarin and direct-acting drug groups, the stroke rate was also greater than 3% per year in both subgroups, and bleeding events occurred at rates of greater than 4% per year among the patients treated with direct-acting drugs and greater than 5% per year in the warfarin group.
Hein Heidbuchel, MD, professor of medicine and chair of cardiology at the University of Antwerp, Belgium, made these comments as designated discussant for the study. He had no current disclosures.
What is clear from this analysis is that adherence to oral anticoagulant regimens is something we need to address. It would help if we could determine why patients are not well adherent, but regardless of the cause, changing patient behavior and improving adherence will require better patient education and better integration of medical care toward better adherence.
This study has several obvious limitations, including its reliance on an administrative database that does not allow for adjudication of outcomes. The analysis presented so far is also limited by not breaking down the direct-acting oral anticoagulant into individual drugs, and without propensity-score matching of the two treatment subgroups.
We must be very alert to the possibility for confounding by indication in a real-world dataset like this. For example, the stroke rate we see in the patients treated with a DOAC may be affected by clinicians who preferentially prescribed one of the direct-acting drugs to patients who had what they thought was a high stroke risk because they felt these drugs might work better for stroke prevention than warfarin.
What is also notable in the results is that, even among the patients with good adherence, the event and adverse effects rates remained high. Among the highly adherent patients the thromboembolic event rate was greater than 3% per year in both the warfarin and direct-acting drug groups, the stroke rate was also greater than 3% per year in both subgroups, and bleeding events occurred at rates of greater than 4% per year among the patients treated with direct-acting drugs and greater than 5% per year in the warfarin group.
Hein Heidbuchel, MD, professor of medicine and chair of cardiology at the University of Antwerp, Belgium, made these comments as designated discussant for the study. He had no current disclosures.
What is clear from this analysis is that adherence to oral anticoagulant regimens is something we need to address. It would help if we could determine why patients are not well adherent, but regardless of the cause, changing patient behavior and improving adherence will require better patient education and better integration of medical care toward better adherence.
This study has several obvious limitations, including its reliance on an administrative database that does not allow for adjudication of outcomes. The analysis presented so far is also limited by not breaking down the direct-acting oral anticoagulant into individual drugs, and without propensity-score matching of the two treatment subgroups.
We must be very alert to the possibility for confounding by indication in a real-world dataset like this. For example, the stroke rate we see in the patients treated with a DOAC may be affected by clinicians who preferentially prescribed one of the direct-acting drugs to patients who had what they thought was a high stroke risk because they felt these drugs might work better for stroke prevention than warfarin.
What is also notable in the results is that, even among the patients with good adherence, the event and adverse effects rates remained high. Among the highly adherent patients the thromboembolic event rate was greater than 3% per year in both the warfarin and direct-acting drug groups, the stroke rate was also greater than 3% per year in both subgroups, and bleeding events occurred at rates of greater than 4% per year among the patients treated with direct-acting drugs and greater than 5% per year in the warfarin group.
Hein Heidbuchel, MD, professor of medicine and chair of cardiology at the University of Antwerp, Belgium, made these comments as designated discussant for the study. He had no current disclosures.
BOSTON – The direct acting oral anticoagulants boost patient adherence compared with warfarin anticoagulation, but when patients did not adhere to their regimens, those prescribed a new, direct-acting oral anticoagulant had worse outcomes than did patients on warfarin – even patients poorly adherent with warfarin – based on data from more than 80,000 U.S. patients.
Among low-adherence patients, defined as those with adherence rates of 40%-80% based on prescriptions filled, patients with nonvalvular atrial fibrillation and a CHA2DS2-VASc score of at least 2 and treated with warfarin had a 3.37/100 patient-years rate of thromboembolic events–driven hospitalizations or emergency department visits, compared with a 4.05/100 patient-years rate among low-adherence patients receiving a direct-acting oral anticoagulant (DOAC), Dhanunjaya Lakkireddy, MD, said at the annual scientific sessions of the Heart Rhythm Society. The incidence of strokes of any kind was also lower in the low-adherence warfarin patients compared with the low-adherence DOAC patients, although the relationship flipped for hemorrhagic strokes and bleeds, which were more common in the warfarin patients.
In contrast, when patients were adherent, taking more than 80% of their prescribed drug, the performance of the DOACs generally surpassed that of warfarin. In an analysis adjusted for several demographic and clinical confounders, and when compared with patients adherent to a warfarin regimen, those adherent to a DOAC had a 7% lower rate of thromboembolic events, a 36% lower rate of hemorrhagic strokes, an 8% lower rate of any stroke, and a 10% lower rate of bleeds (excluding hemorrhagic strokes), all statistically significant differences, reported Dr. Lakkireddy, medical director of the Kansas City Heart Rhythm Institute in Overland Park, Kan.
The message from this analysis is the importance of maximizing patient adherence, Dr. Lakkireddy said.
“We should not make the false assumption that putting a patient on a DOAC will take care of everything. We need to make it a habit to make sure patients are taking their pills,” he said in an interview. “We were surprised. Our assumption was that the DOACs were more forgiving than warfarin” in poorly compliant patients. “We need to make talking about adherence with patients routine.”
The results also documented that adherence to therapy is better with a DOAC, with a 74% rate of good adherence among the nearly 41,000 patients in the database prescribed a DOAC compared with a 63% rate of good compliance among the more than 42,000 patients prescribed warfarin.
“It’s ironic that we might think low-adherence patients should go on warfarin. That’s sort of backwards,” said Andrew D. Krahn, MD, a cardiac electrophysiologist and professor of medicine at the University of British Columbia in Vancouver. “It’s not biologically plausible” to predict that less adherent patients would do better on warfarin, he noted.
The study run by Dr. Lakkireddy and his associates used data collected by IBM Watson Health Market Scan from about 4 million Medicare patients and 47 million American residents with private insurance during 2012-2016. They focused on the more than 600,000 patients prescribed an anticoagulant during 2014 and 2015, and then narrowed the study group down to just over 83,000 adults with nonvalvular atrial fibrillation, a CHA2DS2-VASc score of 2 or more. The patients’ average age was about 74 years.
Dr. Lakkireddy has been a consultant to or has received research support from Biosense Webster, Boehringer Ingelheim, Bristol Myers Squibb, EstechPharma, Janssen, Pfizer, SentreHeart, and St. Jude. Dr. Krahn has been a consultant to Medtronic and has received research support from Medtronic and Boston Scientific.
SOURCE: Lakkireddy D et al. Heart Rhythm 2018, Abstract B-LBCT02-03.
BOSTON – The direct acting oral anticoagulants boost patient adherence compared with warfarin anticoagulation, but when patients did not adhere to their regimens, those prescribed a new, direct-acting oral anticoagulant had worse outcomes than did patients on warfarin – even patients poorly adherent with warfarin – based on data from more than 80,000 U.S. patients.
Among low-adherence patients, defined as those with adherence rates of 40%-80% based on prescriptions filled, patients with nonvalvular atrial fibrillation and a CHA2DS2-VASc score of at least 2 and treated with warfarin had a 3.37/100 patient-years rate of thromboembolic events–driven hospitalizations or emergency department visits, compared with a 4.05/100 patient-years rate among low-adherence patients receiving a direct-acting oral anticoagulant (DOAC), Dhanunjaya Lakkireddy, MD, said at the annual scientific sessions of the Heart Rhythm Society. The incidence of strokes of any kind was also lower in the low-adherence warfarin patients compared with the low-adherence DOAC patients, although the relationship flipped for hemorrhagic strokes and bleeds, which were more common in the warfarin patients.
In contrast, when patients were adherent, taking more than 80% of their prescribed drug, the performance of the DOACs generally surpassed that of warfarin. In an analysis adjusted for several demographic and clinical confounders, and when compared with patients adherent to a warfarin regimen, those adherent to a DOAC had a 7% lower rate of thromboembolic events, a 36% lower rate of hemorrhagic strokes, an 8% lower rate of any stroke, and a 10% lower rate of bleeds (excluding hemorrhagic strokes), all statistically significant differences, reported Dr. Lakkireddy, medical director of the Kansas City Heart Rhythm Institute in Overland Park, Kan.
The message from this analysis is the importance of maximizing patient adherence, Dr. Lakkireddy said.
“We should not make the false assumption that putting a patient on a DOAC will take care of everything. We need to make it a habit to make sure patients are taking their pills,” he said in an interview. “We were surprised. Our assumption was that the DOACs were more forgiving than warfarin” in poorly compliant patients. “We need to make talking about adherence with patients routine.”
The results also documented that adherence to therapy is better with a DOAC, with a 74% rate of good adherence among the nearly 41,000 patients in the database prescribed a DOAC compared with a 63% rate of good compliance among the more than 42,000 patients prescribed warfarin.
“It’s ironic that we might think low-adherence patients should go on warfarin. That’s sort of backwards,” said Andrew D. Krahn, MD, a cardiac electrophysiologist and professor of medicine at the University of British Columbia in Vancouver. “It’s not biologically plausible” to predict that less adherent patients would do better on warfarin, he noted.
The study run by Dr. Lakkireddy and his associates used data collected by IBM Watson Health Market Scan from about 4 million Medicare patients and 47 million American residents with private insurance during 2012-2016. They focused on the more than 600,000 patients prescribed an anticoagulant during 2014 and 2015, and then narrowed the study group down to just over 83,000 adults with nonvalvular atrial fibrillation, a CHA2DS2-VASc score of 2 or more. The patients’ average age was about 74 years.
Dr. Lakkireddy has been a consultant to or has received research support from Biosense Webster, Boehringer Ingelheim, Bristol Myers Squibb, EstechPharma, Janssen, Pfizer, SentreHeart, and St. Jude. Dr. Krahn has been a consultant to Medtronic and has received research support from Medtronic and Boston Scientific.
SOURCE: Lakkireddy D et al. Heart Rhythm 2018, Abstract B-LBCT02-03.
REPORTING FROM HEART RHYTHM 2018
Key clinical point: Good adherence is needed for direct-acting oral anticoagulants to outperform warfarin.
Major finding: Thromboembolic events in low-adherence patients were 4.05/100 patient years with a DOAC and 3.37/100 patient years with warfarin.
Study details: Analysis of 83,168 insured U.S. atrial fibrillation patients treated with an oral anticoagulant in 2014-2015.
Disclosures: Dr. Lakkireddy has been a consultant to or has received research support from Biosense Webster, Boehringer Ingelheim, Bristol Myers Squibb, EstechPharma, Janssen, Pfizer, SentreHeart, and St. Jude. Dr. Krahn has been a consultant to Medtronic and has received research support from Medtronic and Boston Scientific.
Source: Lakkireddy D et al. Heart Rhythm 2018, Abstract B-LBCT02-03.
The work schedule that prevents burnout
The schedule is easier to change than the work itself
Burnout is influenced by a seemingly infinite combination of variables. An optimal schedule alone isn’t the key to preventing it, but maybe a good schedule can reduce your risk you’ll suffer from it.
Smart people who have spent years as hospitalists, working multiple different schedules, have formed a variety of conclusions about which work schedules best reduce the risk of burnout. There’s no meaningful research to settle the question, so everyone will have to reach their own conclusions, as I’ve done here.
Scheduling flexibility: Often overlooked?
Someone who typically works the same number of consecutive day shifts, each of which is the same duration, might suffer from the monotony and inexorable predictability. Schedules that vary the number of consecutive day shifts, the intensity or length of shifts, and the number of consecutive days off might result in lower rates of burnout. This is especially likely to be the case if each provider has some flexibility to control how her schedule varies over time.
Personal time goes on the calendar first
Those who have a regularly repeating work schedule tend to work hard arranging such important things as family vacations on days the schedule dictates. In other words, the first thing that goes on the personal calendar are the weeks of work; they’re “X-ed” out and personal events filled into the remaining days.
That’s fine for many personal activities, but it means the hospitalist might tend to set a pretty high bar for activities that are worth negotiating alterations to the usual schedule. For example, you might want to see U2 but decide to skip their concert in your town since it falls in the middle of your regularly scheduled week of work. Maybe that’s not a big deal (Isn’t U2 overplayed and out of date anyway?), but an accumulation of small sacrifices like this might increase resentment of work.
It’s possible to organize a hospitalist group schedule in which each provider’s personally requested days off, like the U2 concert, go on the work calendar first, and the clinical schedule is built around them. It can get pretty time consuming to manage, but might be a worthwhile investment to reduce burnout risk.
A paradox: Fewer shifts could increase burnout risk
I’m convinced many hospitalists make the mistake of seeking to maximize their number of days off with the idea that it will be good for happiness, career longevity, burnout, etc. While having more days off provides more time for nonwork activities and rest/recovery from work, it usually means the average workday is busier and more stressful to maintain expected levels of productivity. The net effect for some seems to be increased burnout.
Consider someone who has been working 182 hospitalist shifts and generating a total of 2,114 billed encounters annually (both are the most recent national medians available from surveys). This hospitalist successfully negotiates a reduction to 161 annual shifts. This would probably feel good to anyone at first, but keep in mind that it means the average number of daily encounters to maintain median annual productivity would increase 13% (from 11.6 to 13.1 in this example). That is, each day of work just got 13% busier.
I regularly encounter career hospitalists with more than 10 years of experience who say they still appreciate – or even are addicted to – having lots of days off. But the worked days often are so busy they don’t know how long they can keep doing it. It is possible some of them might be happier and less burned out if they work more shifts annually, and the average shift is meaningfully less busy.
The “right” number of shifts depends on a combination of personal and economic factors. Rather than focusing almost exclusively on the number of shifts worked annually, it may be better to think about the total amount of annual work measured in billed encounters, or wRVUs [work relative value units], and how it is titrated out on the calendar.
Other scheduling attributes and burnout
I think it’s really important to ensure the hospitalist group always has the target number of providers working each day. Many groups have experienced staffing deficits for so long that they’ve essentially given up on this goal, and staffing levels vary day to day. This means each provider has uncertainty regarding how often he will be scheduled on days with fewer than the targeted numbers of providers working.
All hospitalist groups should ensure their schedule has day-shift providers work a meaningful series of shifts consecutively to support good patient-provider continuity. I think “continuity is king” and influences efficiency, quality of care, and provider burnout. Of course, there is tension between working many consecutive day shifts and still having a reasonable lifestyle; you’ll have to make up your own mind about the sweet spot between these to competing needs.
Schedule and number of shifts are only part of the burnout picture. The nature of hospitalist work, including EHR frustrations and distressing conversations regarding observation status, etc., probably has more significant influence on burnout and job satisfaction than does the work schedule itself.
But there is still lots of value in thinking carefully about your group’s work schedule and making adjustments where needed. The schedule is a lot easier to change than the nature of the work itself.
Dr. Nelson has had a career in clinical practice as a hospitalist starting in 1988. He is cofounder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice management courses. Contact him at [email protected].
The schedule is easier to change than the work itself
The schedule is easier to change than the work itself
Burnout is influenced by a seemingly infinite combination of variables. An optimal schedule alone isn’t the key to preventing it, but maybe a good schedule can reduce your risk you’ll suffer from it.
Smart people who have spent years as hospitalists, working multiple different schedules, have formed a variety of conclusions about which work schedules best reduce the risk of burnout. There’s no meaningful research to settle the question, so everyone will have to reach their own conclusions, as I’ve done here.
Scheduling flexibility: Often overlooked?
Someone who typically works the same number of consecutive day shifts, each of which is the same duration, might suffer from the monotony and inexorable predictability. Schedules that vary the number of consecutive day shifts, the intensity or length of shifts, and the number of consecutive days off might result in lower rates of burnout. This is especially likely to be the case if each provider has some flexibility to control how her schedule varies over time.
Personal time goes on the calendar first
Those who have a regularly repeating work schedule tend to work hard arranging such important things as family vacations on days the schedule dictates. In other words, the first thing that goes on the personal calendar are the weeks of work; they’re “X-ed” out and personal events filled into the remaining days.
That’s fine for many personal activities, but it means the hospitalist might tend to set a pretty high bar for activities that are worth negotiating alterations to the usual schedule. For example, you might want to see U2 but decide to skip their concert in your town since it falls in the middle of your regularly scheduled week of work. Maybe that’s not a big deal (Isn’t U2 overplayed and out of date anyway?), but an accumulation of small sacrifices like this might increase resentment of work.
It’s possible to organize a hospitalist group schedule in which each provider’s personally requested days off, like the U2 concert, go on the work calendar first, and the clinical schedule is built around them. It can get pretty time consuming to manage, but might be a worthwhile investment to reduce burnout risk.
A paradox: Fewer shifts could increase burnout risk
I’m convinced many hospitalists make the mistake of seeking to maximize their number of days off with the idea that it will be good for happiness, career longevity, burnout, etc. While having more days off provides more time for nonwork activities and rest/recovery from work, it usually means the average workday is busier and more stressful to maintain expected levels of productivity. The net effect for some seems to be increased burnout.
Consider someone who has been working 182 hospitalist shifts and generating a total of 2,114 billed encounters annually (both are the most recent national medians available from surveys). This hospitalist successfully negotiates a reduction to 161 annual shifts. This would probably feel good to anyone at first, but keep in mind that it means the average number of daily encounters to maintain median annual productivity would increase 13% (from 11.6 to 13.1 in this example). That is, each day of work just got 13% busier.
I regularly encounter career hospitalists with more than 10 years of experience who say they still appreciate – or even are addicted to – having lots of days off. But the worked days often are so busy they don’t know how long they can keep doing it. It is possible some of them might be happier and less burned out if they work more shifts annually, and the average shift is meaningfully less busy.
The “right” number of shifts depends on a combination of personal and economic factors. Rather than focusing almost exclusively on the number of shifts worked annually, it may be better to think about the total amount of annual work measured in billed encounters, or wRVUs [work relative value units], and how it is titrated out on the calendar.
Other scheduling attributes and burnout
I think it’s really important to ensure the hospitalist group always has the target number of providers working each day. Many groups have experienced staffing deficits for so long that they’ve essentially given up on this goal, and staffing levels vary day to day. This means each provider has uncertainty regarding how often he will be scheduled on days with fewer than the targeted numbers of providers working.
All hospitalist groups should ensure their schedule has day-shift providers work a meaningful series of shifts consecutively to support good patient-provider continuity. I think “continuity is king” and influences efficiency, quality of care, and provider burnout. Of course, there is tension between working many consecutive day shifts and still having a reasonable lifestyle; you’ll have to make up your own mind about the sweet spot between these to competing needs.
Schedule and number of shifts are only part of the burnout picture. The nature of hospitalist work, including EHR frustrations and distressing conversations regarding observation status, etc., probably has more significant influence on burnout and job satisfaction than does the work schedule itself.
But there is still lots of value in thinking carefully about your group’s work schedule and making adjustments where needed. The schedule is a lot easier to change than the nature of the work itself.
Dr. Nelson has had a career in clinical practice as a hospitalist starting in 1988. He is cofounder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice management courses. Contact him at [email protected].
Burnout is influenced by a seemingly infinite combination of variables. An optimal schedule alone isn’t the key to preventing it, but maybe a good schedule can reduce your risk you’ll suffer from it.
Smart people who have spent years as hospitalists, working multiple different schedules, have formed a variety of conclusions about which work schedules best reduce the risk of burnout. There’s no meaningful research to settle the question, so everyone will have to reach their own conclusions, as I’ve done here.
Scheduling flexibility: Often overlooked?
Someone who typically works the same number of consecutive day shifts, each of which is the same duration, might suffer from the monotony and inexorable predictability. Schedules that vary the number of consecutive day shifts, the intensity or length of shifts, and the number of consecutive days off might result in lower rates of burnout. This is especially likely to be the case if each provider has some flexibility to control how her schedule varies over time.
Personal time goes on the calendar first
Those who have a regularly repeating work schedule tend to work hard arranging such important things as family vacations on days the schedule dictates. In other words, the first thing that goes on the personal calendar are the weeks of work; they’re “X-ed” out and personal events filled into the remaining days.
That’s fine for many personal activities, but it means the hospitalist might tend to set a pretty high bar for activities that are worth negotiating alterations to the usual schedule. For example, you might want to see U2 but decide to skip their concert in your town since it falls in the middle of your regularly scheduled week of work. Maybe that’s not a big deal (Isn’t U2 overplayed and out of date anyway?), but an accumulation of small sacrifices like this might increase resentment of work.
It’s possible to organize a hospitalist group schedule in which each provider’s personally requested days off, like the U2 concert, go on the work calendar first, and the clinical schedule is built around them. It can get pretty time consuming to manage, but might be a worthwhile investment to reduce burnout risk.
A paradox: Fewer shifts could increase burnout risk
I’m convinced many hospitalists make the mistake of seeking to maximize their number of days off with the idea that it will be good for happiness, career longevity, burnout, etc. While having more days off provides more time for nonwork activities and rest/recovery from work, it usually means the average workday is busier and more stressful to maintain expected levels of productivity. The net effect for some seems to be increased burnout.
Consider someone who has been working 182 hospitalist shifts and generating a total of 2,114 billed encounters annually (both are the most recent national medians available from surveys). This hospitalist successfully negotiates a reduction to 161 annual shifts. This would probably feel good to anyone at first, but keep in mind that it means the average number of daily encounters to maintain median annual productivity would increase 13% (from 11.6 to 13.1 in this example). That is, each day of work just got 13% busier.
I regularly encounter career hospitalists with more than 10 years of experience who say they still appreciate – or even are addicted to – having lots of days off. But the worked days often are so busy they don’t know how long they can keep doing it. It is possible some of them might be happier and less burned out if they work more shifts annually, and the average shift is meaningfully less busy.
The “right” number of shifts depends on a combination of personal and economic factors. Rather than focusing almost exclusively on the number of shifts worked annually, it may be better to think about the total amount of annual work measured in billed encounters, or wRVUs [work relative value units], and how it is titrated out on the calendar.
Other scheduling attributes and burnout
I think it’s really important to ensure the hospitalist group always has the target number of providers working each day. Many groups have experienced staffing deficits for so long that they’ve essentially given up on this goal, and staffing levels vary day to day. This means each provider has uncertainty regarding how often he will be scheduled on days with fewer than the targeted numbers of providers working.
All hospitalist groups should ensure their schedule has day-shift providers work a meaningful series of shifts consecutively to support good patient-provider continuity. I think “continuity is king” and influences efficiency, quality of care, and provider burnout. Of course, there is tension between working many consecutive day shifts and still having a reasonable lifestyle; you’ll have to make up your own mind about the sweet spot between these to competing needs.
Schedule and number of shifts are only part of the burnout picture. The nature of hospitalist work, including EHR frustrations and distressing conversations regarding observation status, etc., probably has more significant influence on burnout and job satisfaction than does the work schedule itself.
But there is still lots of value in thinking carefully about your group’s work schedule and making adjustments where needed. The schedule is a lot easier to change than the nature of the work itself.
Dr. Nelson has had a career in clinical practice as a hospitalist starting in 1988. He is cofounder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice management courses. Contact him at [email protected].
NIH launches HEAL Initiative to combat opioid crisis
The NIH HEAL (Helping to End Addiction Long-term) Initiative aims to bring together agencies across the federal government, as well as academic institutions, private industry, and patient advocates to find new solutions to address the current national health emergency.
“There are 15 initiatives altogether that are being put out that we think are pretty bold and should make a big difference in our understanding of what to do about this national public health crisis,” NIH Director Francis Collins, MD, said in an interview.
HEAL will investigate ways to reformulate existing treatments for opioid use disorder (OUD), to improve efficacy and extend their availability to more patients.
“Although there are effective medications for OUD (methadone, buprenorphine, and naltrexone), only a small percentage of individuals in the United States who would benefit receive these medications,” according to an editorial introducing the NIH HEAL Initiative published in JAMA (doi:10.1001/jama.2018.8826). “Even among those who have initiated these medications, about half will relapse within 6 months.”
The editorial was authored by Dr. Collins, Walter J. Koroshetz, MD, director of the National Institute of Neurological Disorders and Stroke, and Nora Volkow, MD, director of the National Institute on Drug Abuse.
For example, the current formulation of naltrexone lasts about a month within the body, Dr. Collins said in an interview. “If we had a 6-month version of that, I think it would be much more effective because oftentimes the relapses happen after a month or so, before people have fully gotten themselves on the ground.”
Better overdose antidotes are needed as well, he said, particularly for fentanyl overdose. “Narcan may not be strong enough for those long-lasting and very potent opioids like fentanyl,” he said.
HEAL also will seek a better understanding of neonatal opioid withdrawal syndrome (NOWS), also referred to as neonatal abstinence syndrome, which has become alarmingly common as more women of childbearing potential struggle with opioid addiction.
“Innovative methods to identify and treat newborns exposed to opioids, often along with other drugs, have the potential to improve both short- and long-term developmental outcomes in such children,” Dr. Collins and colleagues noted. “To determine better approaches, HEAL will expand Advancing Clinical Trials in Neonatal Opioid Withdrawal Syndrome (ACT NOW). This pilot study is designed to assess the prevalence of NOWS, understand current approaches to managing NOWS , and develop common approaches for larger-scale studies that will determine best practices for clinical care of infants with NOWS throughout the country.”
HEAL efforts also seek to find integrated approaches to OUD treatment.
“One particularly bold element is to put together a number of pilot projects that enable bringing together all of the ways in which we are trying to turn this epidemic around by making it possible to assess whether individuals who are addicted can be successfully treated and maintained in abstinence for long periods of time,” Dr. Collins said. “Right now, the success is not so great.
“Suppose we brought together all of the treatment programs – the primary care facilities, the emergency rooms, the fire departments, the social work experts, the health departments in the states, the local communities, the criminal justice system. We brought together all of those players in a research design where we can really see what was working. Could we do a lot more to turn this around than basically doing one of those at a time? There is this multisite idea of a national research effort, still somewhat in development, but to do integration of all of these efforts. I am pretty excited about that one.”
In looking for better ways to treat pain safely and effectively, “we need to understand how it is that people transition from acute pain to chronic pain … and what can we do increase the likelihood of recovery from acute pain without making that transition,” Dr. Collins said. “Then we need to identify additional novel targets for developing pain therapies, both devices and pharmaceuticals. We need better means of testing those ideas.”
In addition to gaining a better understanding of chronic pain, HEAL aims to investigate new nonaddictive pain treatments and find ways to expedite those treatments through the clinical pipeline, according to Dr. Collins and colleagues.
HEAL “lays the foundation for an innovative therapy-development pipeline through a planned new public-private partnership. In collaboration with biopharmaceutical groups, the Food and Drug Administration, and the Foundation for the NIH, the NIH will collect and evaluate treatment assets from academia and biopharmaceutical and device companies to coordinate and accelerate the development of effective treatments for pain and addiction,” they wrote.
SOURCE: Collins F et al, JAMA doi: 10.1001/jama.2018.8826.
The NIH HEAL (Helping to End Addiction Long-term) Initiative aims to bring together agencies across the federal government, as well as academic institutions, private industry, and patient advocates to find new solutions to address the current national health emergency.
“There are 15 initiatives altogether that are being put out that we think are pretty bold and should make a big difference in our understanding of what to do about this national public health crisis,” NIH Director Francis Collins, MD, said in an interview.
HEAL will investigate ways to reformulate existing treatments for opioid use disorder (OUD), to improve efficacy and extend their availability to more patients.
“Although there are effective medications for OUD (methadone, buprenorphine, and naltrexone), only a small percentage of individuals in the United States who would benefit receive these medications,” according to an editorial introducing the NIH HEAL Initiative published in JAMA (doi:10.1001/jama.2018.8826). “Even among those who have initiated these medications, about half will relapse within 6 months.”
The editorial was authored by Dr. Collins, Walter J. Koroshetz, MD, director of the National Institute of Neurological Disorders and Stroke, and Nora Volkow, MD, director of the National Institute on Drug Abuse.
For example, the current formulation of naltrexone lasts about a month within the body, Dr. Collins said in an interview. “If we had a 6-month version of that, I think it would be much more effective because oftentimes the relapses happen after a month or so, before people have fully gotten themselves on the ground.”
Better overdose antidotes are needed as well, he said, particularly for fentanyl overdose. “Narcan may not be strong enough for those long-lasting and very potent opioids like fentanyl,” he said.
HEAL also will seek a better understanding of neonatal opioid withdrawal syndrome (NOWS), also referred to as neonatal abstinence syndrome, which has become alarmingly common as more women of childbearing potential struggle with opioid addiction.
“Innovative methods to identify and treat newborns exposed to opioids, often along with other drugs, have the potential to improve both short- and long-term developmental outcomes in such children,” Dr. Collins and colleagues noted. “To determine better approaches, HEAL will expand Advancing Clinical Trials in Neonatal Opioid Withdrawal Syndrome (ACT NOW). This pilot study is designed to assess the prevalence of NOWS, understand current approaches to managing NOWS , and develop common approaches for larger-scale studies that will determine best practices for clinical care of infants with NOWS throughout the country.”
HEAL efforts also seek to find integrated approaches to OUD treatment.
“One particularly bold element is to put together a number of pilot projects that enable bringing together all of the ways in which we are trying to turn this epidemic around by making it possible to assess whether individuals who are addicted can be successfully treated and maintained in abstinence for long periods of time,” Dr. Collins said. “Right now, the success is not so great.
“Suppose we brought together all of the treatment programs – the primary care facilities, the emergency rooms, the fire departments, the social work experts, the health departments in the states, the local communities, the criminal justice system. We brought together all of those players in a research design where we can really see what was working. Could we do a lot more to turn this around than basically doing one of those at a time? There is this multisite idea of a national research effort, still somewhat in development, but to do integration of all of these efforts. I am pretty excited about that one.”
In looking for better ways to treat pain safely and effectively, “we need to understand how it is that people transition from acute pain to chronic pain … and what can we do increase the likelihood of recovery from acute pain without making that transition,” Dr. Collins said. “Then we need to identify additional novel targets for developing pain therapies, both devices and pharmaceuticals. We need better means of testing those ideas.”
In addition to gaining a better understanding of chronic pain, HEAL aims to investigate new nonaddictive pain treatments and find ways to expedite those treatments through the clinical pipeline, according to Dr. Collins and colleagues.
HEAL “lays the foundation for an innovative therapy-development pipeline through a planned new public-private partnership. In collaboration with biopharmaceutical groups, the Food and Drug Administration, and the Foundation for the NIH, the NIH will collect and evaluate treatment assets from academia and biopharmaceutical and device companies to coordinate and accelerate the development of effective treatments for pain and addiction,” they wrote.
SOURCE: Collins F et al, JAMA doi: 10.1001/jama.2018.8826.
The NIH HEAL (Helping to End Addiction Long-term) Initiative aims to bring together agencies across the federal government, as well as academic institutions, private industry, and patient advocates to find new solutions to address the current national health emergency.
“There are 15 initiatives altogether that are being put out that we think are pretty bold and should make a big difference in our understanding of what to do about this national public health crisis,” NIH Director Francis Collins, MD, said in an interview.
HEAL will investigate ways to reformulate existing treatments for opioid use disorder (OUD), to improve efficacy and extend their availability to more patients.
“Although there are effective medications for OUD (methadone, buprenorphine, and naltrexone), only a small percentage of individuals in the United States who would benefit receive these medications,” according to an editorial introducing the NIH HEAL Initiative published in JAMA (doi:10.1001/jama.2018.8826). “Even among those who have initiated these medications, about half will relapse within 6 months.”
The editorial was authored by Dr. Collins, Walter J. Koroshetz, MD, director of the National Institute of Neurological Disorders and Stroke, and Nora Volkow, MD, director of the National Institute on Drug Abuse.
For example, the current formulation of naltrexone lasts about a month within the body, Dr. Collins said in an interview. “If we had a 6-month version of that, I think it would be much more effective because oftentimes the relapses happen after a month or so, before people have fully gotten themselves on the ground.”
Better overdose antidotes are needed as well, he said, particularly for fentanyl overdose. “Narcan may not be strong enough for those long-lasting and very potent opioids like fentanyl,” he said.
HEAL also will seek a better understanding of neonatal opioid withdrawal syndrome (NOWS), also referred to as neonatal abstinence syndrome, which has become alarmingly common as more women of childbearing potential struggle with opioid addiction.
“Innovative methods to identify and treat newborns exposed to opioids, often along with other drugs, have the potential to improve both short- and long-term developmental outcomes in such children,” Dr. Collins and colleagues noted. “To determine better approaches, HEAL will expand Advancing Clinical Trials in Neonatal Opioid Withdrawal Syndrome (ACT NOW). This pilot study is designed to assess the prevalence of NOWS, understand current approaches to managing NOWS , and develop common approaches for larger-scale studies that will determine best practices for clinical care of infants with NOWS throughout the country.”
HEAL efforts also seek to find integrated approaches to OUD treatment.
“One particularly bold element is to put together a number of pilot projects that enable bringing together all of the ways in which we are trying to turn this epidemic around by making it possible to assess whether individuals who are addicted can be successfully treated and maintained in abstinence for long periods of time,” Dr. Collins said. “Right now, the success is not so great.
“Suppose we brought together all of the treatment programs – the primary care facilities, the emergency rooms, the fire departments, the social work experts, the health departments in the states, the local communities, the criminal justice system. We brought together all of those players in a research design where we can really see what was working. Could we do a lot more to turn this around than basically doing one of those at a time? There is this multisite idea of a national research effort, still somewhat in development, but to do integration of all of these efforts. I am pretty excited about that one.”
In looking for better ways to treat pain safely and effectively, “we need to understand how it is that people transition from acute pain to chronic pain … and what can we do increase the likelihood of recovery from acute pain without making that transition,” Dr. Collins said. “Then we need to identify additional novel targets for developing pain therapies, both devices and pharmaceuticals. We need better means of testing those ideas.”
In addition to gaining a better understanding of chronic pain, HEAL aims to investigate new nonaddictive pain treatments and find ways to expedite those treatments through the clinical pipeline, according to Dr. Collins and colleagues.
HEAL “lays the foundation for an innovative therapy-development pipeline through a planned new public-private partnership. In collaboration with biopharmaceutical groups, the Food and Drug Administration, and the Foundation for the NIH, the NIH will collect and evaluate treatment assets from academia and biopharmaceutical and device companies to coordinate and accelerate the development of effective treatments for pain and addiction,” they wrote.
SOURCE: Collins F et al, JAMA doi: 10.1001/jama.2018.8826.
FROM JAMA
CMS sepsis measure a challenge to report
Hospitalists can champion sepsis-improvement efforts
In October 2015, the Centers for Medicare & Medicaid Services implemented its first meaningful policy to attempt for addressing sepsis.
The condition – one of the leading causes of mortality among hospitalized patients – afflicts more than a million people each year in the United States, and between 15% and 30% of them die. Sepsis is one of the leading drivers of hospital readmissions, sending more patients back to the hospital than heart failure, pneumonia, and chronic obstructive pulmonary disease.1
However, while providers seem to agree that time to address sepsis is past due, not everyone has embraced the Sepsis CMS Core Measure program, or SEP-1, as the means to best achieve it. This is, in part, because of discrepancies in how sepsis is defined, the burden of reporting, and what some consider to be arbitrary clinical requirements that may not correlate with better patient outcomes.
“Sepsis is indeed a critical public health problem, and it’s appropriate and valuable that Medicare and other policy makers are focusing on sepsis,” said Jeremy Kahn, MD, professor of critical care medicine and health policy and management at the University of Pittsburgh. “This was really the first approach at that … but at 85-pages long, it really is an enormous effort for hospitals to adhere to this measure.”
This is because of the tension between the “intense desire to improve sepsis outcomes” and the “incredible burden” of keeping up with the necessary documentation while also providing quality care, Dr. Kahn said.
In December 2017, Dr. Kahn helped lead a study published in the Journal of Hospital Medicine aimed at trying to understand hospital perceptions of SEP-1. Over the course of 29 interviews with randomly selected hospital quality leaders across the United States, including physicians and nurses, the results came as a surprise.2
“Generally, hospitals were very supportive of the concept, and there was no pushback on the idea that we should be measuring and reporting sepsis quality to CMS,” he said.
However, the research team found that respondents believed the program’s requirements with respect to treatment and documentation were complex and not always linked to patient-centered outcomes. Meeting the SEP-1 bundles consistently required hospitals to dedicate resources that not all may have, especially those in small, rural communities and those serving as urban safety nets.
Some, like emergency medicine physician Annahieta Kalantari, DO (who did not participate in the survey), feel that SEP-1 forces providers to practice “check-box” medicine and undermines successful efforts that don’t necessarily align with the CMS policy.
She arrived at her institution, Aria-Jefferson Health in Philadelphia, before CMS adopted SEP-1; at that time, she took note of the fact that the rate of sepsis mortalities in her hospital was, in her words, not great when compared with that at similar institutions. And then she helped do something about it.
“I thought, ‘We’re a Premier reporting hospital,’ so we did a gap analysis as to why and put together protocols for the hospital to follow with our sepsis patients, including a sepsis alert and a lot of education,” said Dr. Kalantari, associate program director for the emergency medicine residency program at Aria-Jefferson and a former chair of its sepsis management committee. “Before you knew it, mortalities were below benchmark.”
But once SEP-1 began, she said, the hospital was unable to check all of the boxes all of the time.
“We kept track, but we weren’t hitting all the bundles exactly within the periods of time recommended, but our mortalities were still amazing,” she said. “CMS basically picked definitions [for sepsis], and most of us don’t know what they’re basing them on because no one can agree on a definition anyway. Now they’re penalizing hospitals if they don’t hit the check marks in time, but we’d already demonstrated that our mortality and patient care was exceptional.”
She added: “I am extremely dissatisfied, as someone who provides frontline patient care, with how CMS is choosing to measure us.”
Dr. Kalantari wrote a piece in the Western Journal of Emergency Medicine in July 2017 in which she and coauthors outline the issues they take with SEP-1. They lay out the tension among the varied definitions of what sepsis is – and isn’t – and they also illuminate the apparent conflict between what CMS has officially defined and what evidence-based studies conducted since 2001 have suggested.3
In particular, CMS defines severe sepsis as an initial lactate above 2 mmol/L and septic shock as an initial lactate presentation of greater than 4 mmol/L. However, Dr. Kalantari and here coauthors argue in the paper that there is no standard definition of sepsis and that decades of attempts to achieve one have failed to reach consensus among providers. CMS, she said, fails to acknowledge this.
Defining sepsis
In fact, in 2016, another new definition of sepsis emerged by way of a 19-member task-force of experts: The Third International Consensus Definitions for Sepsis and Septic Shock, also called Sepsis-3.4 In March 2017, the Surviving Sepsis Campaign adopted this definition, which defined sepsis as a “life-threatening organ dysfunction caused by a dysregulated host response to infection.”5
“I think the definition has always been a challenging part of sepsis,” said Kencee Graves, MD, a hospitalist at the University of Utah, Salt Lake City. “The definitions came about for research purposes, so … they are not perfectly sensitive nor specific.”
However, Dr. Graves believes SEP-1 is a step in the right direction in that it brings awareness to sepsis and holds providers accountable. Several years ago, she and her colleague Devin Horton, MD, also a hospitalist at the University of Utah, embarked on a massive undertaking to address sepsis in their hospital. It was, at the time, lacking in “sepsis culture,” Dr. Horton said.
“One of the big things that motivated both of us was that we started doing chart review together and – it’s always easier with 20/20 hindsight – we were noticing that residents were missing the signs of sepsis,” Dr. Horton explained. “The clinical criteria would be there, but no one would say the word.” This is important, he said, because sepsis is time critical.
So the pair set out to create a cultural change by sharing data and collecting input from each service and unit, which relied heavily on nursing staff to perpetuate change. They created an early warning system in the medical record and worked with units to achieve flexibility in their criteria.
While the early warning system seemed helpful on the floor, SEP-1 adherence rates changed little in the emergency department. So Dr. Graves and Dr. Horton worked out an ED-specific process map that started at triage and was modeled after myocardial infarction STEMI protocols. From April through December 2016, the ED achieved between 29.5% adherence to the SEP-1 bundles, they said according to CMS abstractor data. After the change, between January and March 2017, the ED saw 52.2% adherence.
Dr. Kalantari would like to see CMS allow hospitals to evaluate and alter their processes more individually, with the required result being lower sepsis mortality. Hospitalists, said Dr. Kahn, are well poised to champion these sepsis improvement efforts.
“Hospitalists are uniquely positioned to lead in this area because they are a visible presence and a link between providers doing multidisciplinary acute care,” he said. “The other thing hospitalists can do is insist on rolling out approaches that are evidence based and not likely to cause harm by leading to over resuscitation, or ensuring patients are receiving central-line insertions only when needed.”
This is currently a moment for hospitals to innovate and provide meaningful feedback to CMS, which, he said, is listening.
“It’s a myth that CMS rolls out policy without listening to the clinical community, but what they want is constructive criticism, not just to hear ‘We’re not ready and we have to push this down the road,’ ” Dr. Kahn said. “The time is now in the era of accountability in health care.”
References
1. Sepsis. National Institute of General Medical Sciences. https://www.nigms.nih.gov/education/pages/factsheet_sepsis.aspx. Updated Sept 2017. Accessed Jan 4, 2018.
2. Barbash I et al. Hospital perceptions of Medicare’s sepsis quality reporting initiative. J Hosp Med. 2017;12;963-8.
3. Kalantari A et al. Sepsis Definitions: The search for gold and what CMS got wrong. West J Emerg Med. 2017 Aug;18(5):951-6.
4. Singer M et. al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):801-10.
5. Rhodes A et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017;43:304.
Hospitalists can champion sepsis-improvement efforts
Hospitalists can champion sepsis-improvement efforts
In October 2015, the Centers for Medicare & Medicaid Services implemented its first meaningful policy to attempt for addressing sepsis.
The condition – one of the leading causes of mortality among hospitalized patients – afflicts more than a million people each year in the United States, and between 15% and 30% of them die. Sepsis is one of the leading drivers of hospital readmissions, sending more patients back to the hospital than heart failure, pneumonia, and chronic obstructive pulmonary disease.1
However, while providers seem to agree that time to address sepsis is past due, not everyone has embraced the Sepsis CMS Core Measure program, or SEP-1, as the means to best achieve it. This is, in part, because of discrepancies in how sepsis is defined, the burden of reporting, and what some consider to be arbitrary clinical requirements that may not correlate with better patient outcomes.
“Sepsis is indeed a critical public health problem, and it’s appropriate and valuable that Medicare and other policy makers are focusing on sepsis,” said Jeremy Kahn, MD, professor of critical care medicine and health policy and management at the University of Pittsburgh. “This was really the first approach at that … but at 85-pages long, it really is an enormous effort for hospitals to adhere to this measure.”
This is because of the tension between the “intense desire to improve sepsis outcomes” and the “incredible burden” of keeping up with the necessary documentation while also providing quality care, Dr. Kahn said.
In December 2017, Dr. Kahn helped lead a study published in the Journal of Hospital Medicine aimed at trying to understand hospital perceptions of SEP-1. Over the course of 29 interviews with randomly selected hospital quality leaders across the United States, including physicians and nurses, the results came as a surprise.2
“Generally, hospitals were very supportive of the concept, and there was no pushback on the idea that we should be measuring and reporting sepsis quality to CMS,” he said.
However, the research team found that respondents believed the program’s requirements with respect to treatment and documentation were complex and not always linked to patient-centered outcomes. Meeting the SEP-1 bundles consistently required hospitals to dedicate resources that not all may have, especially those in small, rural communities and those serving as urban safety nets.
Some, like emergency medicine physician Annahieta Kalantari, DO (who did not participate in the survey), feel that SEP-1 forces providers to practice “check-box” medicine and undermines successful efforts that don’t necessarily align with the CMS policy.
She arrived at her institution, Aria-Jefferson Health in Philadelphia, before CMS adopted SEP-1; at that time, she took note of the fact that the rate of sepsis mortalities in her hospital was, in her words, not great when compared with that at similar institutions. And then she helped do something about it.
“I thought, ‘We’re a Premier reporting hospital,’ so we did a gap analysis as to why and put together protocols for the hospital to follow with our sepsis patients, including a sepsis alert and a lot of education,” said Dr. Kalantari, associate program director for the emergency medicine residency program at Aria-Jefferson and a former chair of its sepsis management committee. “Before you knew it, mortalities were below benchmark.”
But once SEP-1 began, she said, the hospital was unable to check all of the boxes all of the time.
“We kept track, but we weren’t hitting all the bundles exactly within the periods of time recommended, but our mortalities were still amazing,” she said. “CMS basically picked definitions [for sepsis], and most of us don’t know what they’re basing them on because no one can agree on a definition anyway. Now they’re penalizing hospitals if they don’t hit the check marks in time, but we’d already demonstrated that our mortality and patient care was exceptional.”
She added: “I am extremely dissatisfied, as someone who provides frontline patient care, with how CMS is choosing to measure us.”
Dr. Kalantari wrote a piece in the Western Journal of Emergency Medicine in July 2017 in which she and coauthors outline the issues they take with SEP-1. They lay out the tension among the varied definitions of what sepsis is – and isn’t – and they also illuminate the apparent conflict between what CMS has officially defined and what evidence-based studies conducted since 2001 have suggested.3
In particular, CMS defines severe sepsis as an initial lactate above 2 mmol/L and septic shock as an initial lactate presentation of greater than 4 mmol/L. However, Dr. Kalantari and here coauthors argue in the paper that there is no standard definition of sepsis and that decades of attempts to achieve one have failed to reach consensus among providers. CMS, she said, fails to acknowledge this.
Defining sepsis
In fact, in 2016, another new definition of sepsis emerged by way of a 19-member task-force of experts: The Third International Consensus Definitions for Sepsis and Septic Shock, also called Sepsis-3.4 In March 2017, the Surviving Sepsis Campaign adopted this definition, which defined sepsis as a “life-threatening organ dysfunction caused by a dysregulated host response to infection.”5
“I think the definition has always been a challenging part of sepsis,” said Kencee Graves, MD, a hospitalist at the University of Utah, Salt Lake City. “The definitions came about for research purposes, so … they are not perfectly sensitive nor specific.”
However, Dr. Graves believes SEP-1 is a step in the right direction in that it brings awareness to sepsis and holds providers accountable. Several years ago, she and her colleague Devin Horton, MD, also a hospitalist at the University of Utah, embarked on a massive undertaking to address sepsis in their hospital. It was, at the time, lacking in “sepsis culture,” Dr. Horton said.
“One of the big things that motivated both of us was that we started doing chart review together and – it’s always easier with 20/20 hindsight – we were noticing that residents were missing the signs of sepsis,” Dr. Horton explained. “The clinical criteria would be there, but no one would say the word.” This is important, he said, because sepsis is time critical.
So the pair set out to create a cultural change by sharing data and collecting input from each service and unit, which relied heavily on nursing staff to perpetuate change. They created an early warning system in the medical record and worked with units to achieve flexibility in their criteria.
While the early warning system seemed helpful on the floor, SEP-1 adherence rates changed little in the emergency department. So Dr. Graves and Dr. Horton worked out an ED-specific process map that started at triage and was modeled after myocardial infarction STEMI protocols. From April through December 2016, the ED achieved between 29.5% adherence to the SEP-1 bundles, they said according to CMS abstractor data. After the change, between January and March 2017, the ED saw 52.2% adherence.
Dr. Kalantari would like to see CMS allow hospitals to evaluate and alter their processes more individually, with the required result being lower sepsis mortality. Hospitalists, said Dr. Kahn, are well poised to champion these sepsis improvement efforts.
“Hospitalists are uniquely positioned to lead in this area because they are a visible presence and a link between providers doing multidisciplinary acute care,” he said. “The other thing hospitalists can do is insist on rolling out approaches that are evidence based and not likely to cause harm by leading to over resuscitation, or ensuring patients are receiving central-line insertions only when needed.”
This is currently a moment for hospitals to innovate and provide meaningful feedback to CMS, which, he said, is listening.
“It’s a myth that CMS rolls out policy without listening to the clinical community, but what they want is constructive criticism, not just to hear ‘We’re not ready and we have to push this down the road,’ ” Dr. Kahn said. “The time is now in the era of accountability in health care.”
References
1. Sepsis. National Institute of General Medical Sciences. https://www.nigms.nih.gov/education/pages/factsheet_sepsis.aspx. Updated Sept 2017. Accessed Jan 4, 2018.
2. Barbash I et al. Hospital perceptions of Medicare’s sepsis quality reporting initiative. J Hosp Med. 2017;12;963-8.
3. Kalantari A et al. Sepsis Definitions: The search for gold and what CMS got wrong. West J Emerg Med. 2017 Aug;18(5):951-6.
4. Singer M et. al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):801-10.
5. Rhodes A et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017;43:304.
In October 2015, the Centers for Medicare & Medicaid Services implemented its first meaningful policy to attempt for addressing sepsis.
The condition – one of the leading causes of mortality among hospitalized patients – afflicts more than a million people each year in the United States, and between 15% and 30% of them die. Sepsis is one of the leading drivers of hospital readmissions, sending more patients back to the hospital than heart failure, pneumonia, and chronic obstructive pulmonary disease.1
However, while providers seem to agree that time to address sepsis is past due, not everyone has embraced the Sepsis CMS Core Measure program, or SEP-1, as the means to best achieve it. This is, in part, because of discrepancies in how sepsis is defined, the burden of reporting, and what some consider to be arbitrary clinical requirements that may not correlate with better patient outcomes.
“Sepsis is indeed a critical public health problem, and it’s appropriate and valuable that Medicare and other policy makers are focusing on sepsis,” said Jeremy Kahn, MD, professor of critical care medicine and health policy and management at the University of Pittsburgh. “This was really the first approach at that … but at 85-pages long, it really is an enormous effort for hospitals to adhere to this measure.”
This is because of the tension between the “intense desire to improve sepsis outcomes” and the “incredible burden” of keeping up with the necessary documentation while also providing quality care, Dr. Kahn said.
In December 2017, Dr. Kahn helped lead a study published in the Journal of Hospital Medicine aimed at trying to understand hospital perceptions of SEP-1. Over the course of 29 interviews with randomly selected hospital quality leaders across the United States, including physicians and nurses, the results came as a surprise.2
“Generally, hospitals were very supportive of the concept, and there was no pushback on the idea that we should be measuring and reporting sepsis quality to CMS,” he said.
However, the research team found that respondents believed the program’s requirements with respect to treatment and documentation were complex and not always linked to patient-centered outcomes. Meeting the SEP-1 bundles consistently required hospitals to dedicate resources that not all may have, especially those in small, rural communities and those serving as urban safety nets.
Some, like emergency medicine physician Annahieta Kalantari, DO (who did not participate in the survey), feel that SEP-1 forces providers to practice “check-box” medicine and undermines successful efforts that don’t necessarily align with the CMS policy.
She arrived at her institution, Aria-Jefferson Health in Philadelphia, before CMS adopted SEP-1; at that time, she took note of the fact that the rate of sepsis mortalities in her hospital was, in her words, not great when compared with that at similar institutions. And then she helped do something about it.
“I thought, ‘We’re a Premier reporting hospital,’ so we did a gap analysis as to why and put together protocols for the hospital to follow with our sepsis patients, including a sepsis alert and a lot of education,” said Dr. Kalantari, associate program director for the emergency medicine residency program at Aria-Jefferson and a former chair of its sepsis management committee. “Before you knew it, mortalities were below benchmark.”
But once SEP-1 began, she said, the hospital was unable to check all of the boxes all of the time.
“We kept track, but we weren’t hitting all the bundles exactly within the periods of time recommended, but our mortalities were still amazing,” she said. “CMS basically picked definitions [for sepsis], and most of us don’t know what they’re basing them on because no one can agree on a definition anyway. Now they’re penalizing hospitals if they don’t hit the check marks in time, but we’d already demonstrated that our mortality and patient care was exceptional.”
She added: “I am extremely dissatisfied, as someone who provides frontline patient care, with how CMS is choosing to measure us.”
Dr. Kalantari wrote a piece in the Western Journal of Emergency Medicine in July 2017 in which she and coauthors outline the issues they take with SEP-1. They lay out the tension among the varied definitions of what sepsis is – and isn’t – and they also illuminate the apparent conflict between what CMS has officially defined and what evidence-based studies conducted since 2001 have suggested.3
In particular, CMS defines severe sepsis as an initial lactate above 2 mmol/L and septic shock as an initial lactate presentation of greater than 4 mmol/L. However, Dr. Kalantari and here coauthors argue in the paper that there is no standard definition of sepsis and that decades of attempts to achieve one have failed to reach consensus among providers. CMS, she said, fails to acknowledge this.
Defining sepsis
In fact, in 2016, another new definition of sepsis emerged by way of a 19-member task-force of experts: The Third International Consensus Definitions for Sepsis and Septic Shock, also called Sepsis-3.4 In March 2017, the Surviving Sepsis Campaign adopted this definition, which defined sepsis as a “life-threatening organ dysfunction caused by a dysregulated host response to infection.”5
“I think the definition has always been a challenging part of sepsis,” said Kencee Graves, MD, a hospitalist at the University of Utah, Salt Lake City. “The definitions came about for research purposes, so … they are not perfectly sensitive nor specific.”
However, Dr. Graves believes SEP-1 is a step in the right direction in that it brings awareness to sepsis and holds providers accountable. Several years ago, she and her colleague Devin Horton, MD, also a hospitalist at the University of Utah, embarked on a massive undertaking to address sepsis in their hospital. It was, at the time, lacking in “sepsis culture,” Dr. Horton said.
“One of the big things that motivated both of us was that we started doing chart review together and – it’s always easier with 20/20 hindsight – we were noticing that residents were missing the signs of sepsis,” Dr. Horton explained. “The clinical criteria would be there, but no one would say the word.” This is important, he said, because sepsis is time critical.
So the pair set out to create a cultural change by sharing data and collecting input from each service and unit, which relied heavily on nursing staff to perpetuate change. They created an early warning system in the medical record and worked with units to achieve flexibility in their criteria.
While the early warning system seemed helpful on the floor, SEP-1 adherence rates changed little in the emergency department. So Dr. Graves and Dr. Horton worked out an ED-specific process map that started at triage and was modeled after myocardial infarction STEMI protocols. From April through December 2016, the ED achieved between 29.5% adherence to the SEP-1 bundles, they said according to CMS abstractor data. After the change, between January and March 2017, the ED saw 52.2% adherence.
Dr. Kalantari would like to see CMS allow hospitals to evaluate and alter their processes more individually, with the required result being lower sepsis mortality. Hospitalists, said Dr. Kahn, are well poised to champion these sepsis improvement efforts.
“Hospitalists are uniquely positioned to lead in this area because they are a visible presence and a link between providers doing multidisciplinary acute care,” he said. “The other thing hospitalists can do is insist on rolling out approaches that are evidence based and not likely to cause harm by leading to over resuscitation, or ensuring patients are receiving central-line insertions only when needed.”
This is currently a moment for hospitals to innovate and provide meaningful feedback to CMS, which, he said, is listening.
“It’s a myth that CMS rolls out policy without listening to the clinical community, but what they want is constructive criticism, not just to hear ‘We’re not ready and we have to push this down the road,’ ” Dr. Kahn said. “The time is now in the era of accountability in health care.”
References
1. Sepsis. National Institute of General Medical Sciences. https://www.nigms.nih.gov/education/pages/factsheet_sepsis.aspx. Updated Sept 2017. Accessed Jan 4, 2018.
2. Barbash I et al. Hospital perceptions of Medicare’s sepsis quality reporting initiative. J Hosp Med. 2017;12;963-8.
3. Kalantari A et al. Sepsis Definitions: The search for gold and what CMS got wrong. West J Emerg Med. 2017 Aug;18(5):951-6.
4. Singer M et. al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):801-10.
5. Rhodes A et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017;43:304.
CDC warns of hepatitis A outbreaks in injection drug users
From January 2017 to April 2018, more than 2,500 cases of hepatitis A infection associated with person-to-person transmission were reported to the CDC; of the 1,900 cases where risk factors are known, 68% were related to drug use, homelessness, or both. Various state responses caused a shortage in hepatitis A vaccine during this time, however, because of improvements in controlling outbreaks and an increased vaccine supply, the vaccine has become more available.
Usage of contaminated needles or other injection paraphernalia increase risk of hepatitis A infection, and transience, economic instability, limited health care access, distrust of public officials and public messages, and frequent lack of follow-up contact information in the population who regularly inject drugs make them difficult to reach with preventative services, such as vaccination, use of sterile injection equipment, and case management and contact tracing.
“These challenges make outbreaks among these groups difficult to control,” the CDC said in a statement.
The CDC recommends health departments ensure people who report drug use are vaccinated for hepatitis A, and consider programs to educate at-risk populations, as well as to provide vaccinations in places where at-risk populations may seek treatment. Health care providers should encourage patients who report drug use to be vaccinated for the disease.
For health care professionals, the CDC recommends considering a diagnosis of hepatitis A in any patient with jaundice and clinically compatible symptoms. The agency also recommends one dose of single-antigen hepatitis A vaccine or immune globulin within 2 weeks of exposure for unvaccinated patients who have been exposed to hepatitis A virus.
Find the full Health Advisory on the CDC website.
From January 2017 to April 2018, more than 2,500 cases of hepatitis A infection associated with person-to-person transmission were reported to the CDC; of the 1,900 cases where risk factors are known, 68% were related to drug use, homelessness, or both. Various state responses caused a shortage in hepatitis A vaccine during this time, however, because of improvements in controlling outbreaks and an increased vaccine supply, the vaccine has become more available.
Usage of contaminated needles or other injection paraphernalia increase risk of hepatitis A infection, and transience, economic instability, limited health care access, distrust of public officials and public messages, and frequent lack of follow-up contact information in the population who regularly inject drugs make them difficult to reach with preventative services, such as vaccination, use of sterile injection equipment, and case management and contact tracing.
“These challenges make outbreaks among these groups difficult to control,” the CDC said in a statement.
The CDC recommends health departments ensure people who report drug use are vaccinated for hepatitis A, and consider programs to educate at-risk populations, as well as to provide vaccinations in places where at-risk populations may seek treatment. Health care providers should encourage patients who report drug use to be vaccinated for the disease.
For health care professionals, the CDC recommends considering a diagnosis of hepatitis A in any patient with jaundice and clinically compatible symptoms. The agency also recommends one dose of single-antigen hepatitis A vaccine or immune globulin within 2 weeks of exposure for unvaccinated patients who have been exposed to hepatitis A virus.
Find the full Health Advisory on the CDC website.
From January 2017 to April 2018, more than 2,500 cases of hepatitis A infection associated with person-to-person transmission were reported to the CDC; of the 1,900 cases where risk factors are known, 68% were related to drug use, homelessness, or both. Various state responses caused a shortage in hepatitis A vaccine during this time, however, because of improvements in controlling outbreaks and an increased vaccine supply, the vaccine has become more available.
Usage of contaminated needles or other injection paraphernalia increase risk of hepatitis A infection, and transience, economic instability, limited health care access, distrust of public officials and public messages, and frequent lack of follow-up contact information in the population who regularly inject drugs make them difficult to reach with preventative services, such as vaccination, use of sterile injection equipment, and case management and contact tracing.
“These challenges make outbreaks among these groups difficult to control,” the CDC said in a statement.
The CDC recommends health departments ensure people who report drug use are vaccinated for hepatitis A, and consider programs to educate at-risk populations, as well as to provide vaccinations in places where at-risk populations may seek treatment. Health care providers should encourage patients who report drug use to be vaccinated for the disease.
For health care professionals, the CDC recommends considering a diagnosis of hepatitis A in any patient with jaundice and clinically compatible symptoms. The agency also recommends one dose of single-antigen hepatitis A vaccine or immune globulin within 2 weeks of exposure for unvaccinated patients who have been exposed to hepatitis A virus.
Find the full Health Advisory on the CDC website.
Malnourished U.S. inpatients often go untreated
WASHINGTON – Hospital staffs often fail to treat .
A retrospective review of more than 150,000 patients admitted during a single year at any center within a large, multicenter U.S. hospital system found that even when patients receive oral nutritional supplementation, there is often a substantial delay to its onset.
The data also suggested potential benefits from treating malnutrition with oral nutritional supplementation (ONS). Patients who received ONS had a 10% relative reduction in their rate of 30-day readmission, compared with malnourished patients who did not receive supplements after adjusting for several baseline demographic and clinical variables, Gerard Mullin, MD, said at the annual Digestive Disease Week. His analysis also showed that every doubling of the time from hospital admission to an order for ONS significantly linked with a 6% rise in hospital length of stay.
The findings “highlight the importance of malnutrition screening on admission, starting a nutrition intervention as soon as malnutrition is confirmed, and treating with appropriate ONS,” said Dr. Mullin, a gastroenterologist at Johns Hopkins Medicine in Baltimore and director of the Celiac Disease Clinic. A standard formulation of Ensure was the ONS routinely used at the Johns Hopkins hospitals
“We’re missing malnutrition,” Dr. Mullin said in an interview. The hospital accreditation standards of the Joint Commission call for assessment of the nutritional status of hospitalized patients within 24 hours of admission (Jt Comm J Qual Patient Saf. 2015 Oct;41[10]:469-73). Screening is “not uniformly done,” and when malnutrition is identified, the finding must usually pass through several layers of a hospital’s medico-bureaucratic process before treatment actually starts, he noted. Plus, there’s often dismissal of the importance of intervention. “It’s important to treat patients with ONS sooner than later,” he said.
Dr. Mullin and his associates studied hospital records for 153,161 people admitted to any of the Baltimore-area hospitals in the Johns Hopkins system during October 2016 through the end of September 2017. The hospital staff routinely assessed nutritional status of patients after admission with a two-question screen based on the Malnutrition Screening Tool (Nutrition. 1999 June;15[6]:458-64): Have you had unplanned weight loss of 10 pounds or more during the past 6 months? Have you had decreased oral intake over the past 5 days? This identified 30,284 (20%) who qualified as possibly malnourished by either criterion. The researchers also retrospectively applied a more detailed screen to the patient records using the criteria set by an international consensus guideline committee in 2010 (J Parenter Enteraal Nutr. 2010 Mar-Apr;34[2]:156-9). This identified 8,713 of the hospitalized patients (6%) as malnourished soon after admission. Despite these numbers a scant 274 patients among these 8,713 (3%) actually received ONS, Dr. Mullin reported. In addition, it took an average of 85 hours from the time of each malnourished patient’s admission to when the ONS order appeared in their record.
Dr. Mullin conceded that both the association his group found between treatment with ONS and a reduced rate of 30-day readmission to any of the hospitals in the Johns Hopkins system, and the association between a delay in the time to the start of ONS and length of stay may have been confounded by factors not accounted for in the adjustments they applied. But he maintained that the links are consistent with results from prior studies, and warrant running prospective, randomized studies to better document the impact of ONS on newly admitted patients identified as malnourished.
“We need more of these types of studies and interventional trials to show that ONS makes a difference,” Dr. Mullin said.
The study was sponsored by Abbott, which markets the oral nutritional supplement Ensure. Dr. Mullin had no additional disclosures.
[email protected]
On Twitter @mitchelzoler
SOURCE: Source: Mullin G et al. DDW 2018 presentation 883.
WASHINGTON – Hospital staffs often fail to treat .
A retrospective review of more than 150,000 patients admitted during a single year at any center within a large, multicenter U.S. hospital system found that even when patients receive oral nutritional supplementation, there is often a substantial delay to its onset.
The data also suggested potential benefits from treating malnutrition with oral nutritional supplementation (ONS). Patients who received ONS had a 10% relative reduction in their rate of 30-day readmission, compared with malnourished patients who did not receive supplements after adjusting for several baseline demographic and clinical variables, Gerard Mullin, MD, said at the annual Digestive Disease Week. His analysis also showed that every doubling of the time from hospital admission to an order for ONS significantly linked with a 6% rise in hospital length of stay.
The findings “highlight the importance of malnutrition screening on admission, starting a nutrition intervention as soon as malnutrition is confirmed, and treating with appropriate ONS,” said Dr. Mullin, a gastroenterologist at Johns Hopkins Medicine in Baltimore and director of the Celiac Disease Clinic. A standard formulation of Ensure was the ONS routinely used at the Johns Hopkins hospitals
“We’re missing malnutrition,” Dr. Mullin said in an interview. The hospital accreditation standards of the Joint Commission call for assessment of the nutritional status of hospitalized patients within 24 hours of admission (Jt Comm J Qual Patient Saf. 2015 Oct;41[10]:469-73). Screening is “not uniformly done,” and when malnutrition is identified, the finding must usually pass through several layers of a hospital’s medico-bureaucratic process before treatment actually starts, he noted. Plus, there’s often dismissal of the importance of intervention. “It’s important to treat patients with ONS sooner than later,” he said.
Dr. Mullin and his associates studied hospital records for 153,161 people admitted to any of the Baltimore-area hospitals in the Johns Hopkins system during October 2016 through the end of September 2017. The hospital staff routinely assessed nutritional status of patients after admission with a two-question screen based on the Malnutrition Screening Tool (Nutrition. 1999 June;15[6]:458-64): Have you had unplanned weight loss of 10 pounds or more during the past 6 months? Have you had decreased oral intake over the past 5 days? This identified 30,284 (20%) who qualified as possibly malnourished by either criterion. The researchers also retrospectively applied a more detailed screen to the patient records using the criteria set by an international consensus guideline committee in 2010 (J Parenter Enteraal Nutr. 2010 Mar-Apr;34[2]:156-9). This identified 8,713 of the hospitalized patients (6%) as malnourished soon after admission. Despite these numbers a scant 274 patients among these 8,713 (3%) actually received ONS, Dr. Mullin reported. In addition, it took an average of 85 hours from the time of each malnourished patient’s admission to when the ONS order appeared in their record.
Dr. Mullin conceded that both the association his group found between treatment with ONS and a reduced rate of 30-day readmission to any of the hospitals in the Johns Hopkins system, and the association between a delay in the time to the start of ONS and length of stay may have been confounded by factors not accounted for in the adjustments they applied. But he maintained that the links are consistent with results from prior studies, and warrant running prospective, randomized studies to better document the impact of ONS on newly admitted patients identified as malnourished.
“We need more of these types of studies and interventional trials to show that ONS makes a difference,” Dr. Mullin said.
The study was sponsored by Abbott, which markets the oral nutritional supplement Ensure. Dr. Mullin had no additional disclosures.
[email protected]
On Twitter @mitchelzoler
SOURCE: Source: Mullin G et al. DDW 2018 presentation 883.
WASHINGTON – Hospital staffs often fail to treat .
A retrospective review of more than 150,000 patients admitted during a single year at any center within a large, multicenter U.S. hospital system found that even when patients receive oral nutritional supplementation, there is often a substantial delay to its onset.
The data also suggested potential benefits from treating malnutrition with oral nutritional supplementation (ONS). Patients who received ONS had a 10% relative reduction in their rate of 30-day readmission, compared with malnourished patients who did not receive supplements after adjusting for several baseline demographic and clinical variables, Gerard Mullin, MD, said at the annual Digestive Disease Week. His analysis also showed that every doubling of the time from hospital admission to an order for ONS significantly linked with a 6% rise in hospital length of stay.
The findings “highlight the importance of malnutrition screening on admission, starting a nutrition intervention as soon as malnutrition is confirmed, and treating with appropriate ONS,” said Dr. Mullin, a gastroenterologist at Johns Hopkins Medicine in Baltimore and director of the Celiac Disease Clinic. A standard formulation of Ensure was the ONS routinely used at the Johns Hopkins hospitals
“We’re missing malnutrition,” Dr. Mullin said in an interview. The hospital accreditation standards of the Joint Commission call for assessment of the nutritional status of hospitalized patients within 24 hours of admission (Jt Comm J Qual Patient Saf. 2015 Oct;41[10]:469-73). Screening is “not uniformly done,” and when malnutrition is identified, the finding must usually pass through several layers of a hospital’s medico-bureaucratic process before treatment actually starts, he noted. Plus, there’s often dismissal of the importance of intervention. “It’s important to treat patients with ONS sooner than later,” he said.
Dr. Mullin and his associates studied hospital records for 153,161 people admitted to any of the Baltimore-area hospitals in the Johns Hopkins system during October 2016 through the end of September 2017. The hospital staff routinely assessed nutritional status of patients after admission with a two-question screen based on the Malnutrition Screening Tool (Nutrition. 1999 June;15[6]:458-64): Have you had unplanned weight loss of 10 pounds or more during the past 6 months? Have you had decreased oral intake over the past 5 days? This identified 30,284 (20%) who qualified as possibly malnourished by either criterion. The researchers also retrospectively applied a more detailed screen to the patient records using the criteria set by an international consensus guideline committee in 2010 (J Parenter Enteraal Nutr. 2010 Mar-Apr;34[2]:156-9). This identified 8,713 of the hospitalized patients (6%) as malnourished soon after admission. Despite these numbers a scant 274 patients among these 8,713 (3%) actually received ONS, Dr. Mullin reported. In addition, it took an average of 85 hours from the time of each malnourished patient’s admission to when the ONS order appeared in their record.
Dr. Mullin conceded that both the association his group found between treatment with ONS and a reduced rate of 30-day readmission to any of the hospitals in the Johns Hopkins system, and the association between a delay in the time to the start of ONS and length of stay may have been confounded by factors not accounted for in the adjustments they applied. But he maintained that the links are consistent with results from prior studies, and warrant running prospective, randomized studies to better document the impact of ONS on newly admitted patients identified as malnourished.
“We need more of these types of studies and interventional trials to show that ONS makes a difference,” Dr. Mullin said.
The study was sponsored by Abbott, which markets the oral nutritional supplement Ensure. Dr. Mullin had no additional disclosures.
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SOURCE: Source: Mullin G et al. DDW 2018 presentation 883.
REPORTING FROM DDW 2018
Key clinical point: Malnourished U.S. hospital inpatients often go untreated.
Major finding: Three percent of patients retrospectively identified as malnourished soon after hospital admission received oral nutritional supplementation.
Study details: Retrospective review of 153,161 patients admitted to a large U.S. hospital network during 2016-2017.
Disclosures: The study was sponsored by Abbott, which markets the oral nutritional supplement Ensure. Dr. Mullin had no additional disclosures.
Source: Mullin G et al. Digestive Disease Week presentation 883.
Education sessions upped COPD patients’ knowledge of their disease
A brief patient-directed education program delivered at the time of hospitalization for an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) improved disease-specific knowledge, according to results of a pilot randomized trial.
Patients who participated in education sessions had a significant improvement in their scores on the Bristol COPD Knowledge Questionnaire (BCKQ), compared with control patients who received no education, study investigators reported in the journal Chest.
“Early education may be a bridge to more active approaches and could provide an important contribution to self-management interventions post-AECOPD,” wrote first author Tania Janaudis-Ferreira, PhD, of the School of Physical and Occupational Therapy, McGill University, Montreal, and her co-authors.
In the study, patients admitted to a community hospital with an AECOPD were randomized to standard care plus brief education or standard care alone. The education consisted of two 30-minute sessions delivered by a physiotherapist, either in the hospital or at home up to 2 weeks after the admission.
Before and after the intervention period, participant knowledge was measured using both the BCKQ and the Lung Information Needs Questionnaire (LINQ).
A total of 31 patients participated, including 15 in the intervention group and 16 in the control group, although 3 patients in the control group did not complete the follow-up testing, investigators said in their report.
The mean change in BCKQ was 8 points for the educational intervention group, and 3.4 for the control group (P = 0.02). That result was in keeping with findings of a previous randomized study noting an 8.3-point change in BCKQ scores for COPD patients who received education in the primary care setting, Dr. Janaudis-Ferreira and co-authors said.
“The change itself is relatively modest, suggesting more frequent sessions might result in greater improvements,” they wrote. For example, they said, an 8-week educational intervention delivered in the context of pulmonary rehabilitation program in one study yielded a mean change of 18.3 points on the BCKQ in the intervention group.
By contrast, the investigators found no significant difference in LINQ score changes between the intervention and control groups (P = .8).
That may indicate that two 30-minute sessions were not sufficient to attend to patients’ learning needs, authors said, though it could also have been an issue with the instrument itself in the setting of this study.
“The majority of the questions in the LINQ ask whether or not a doctor or nurse has explained a specific question to the patient,” authors explained. “Since a physiotherapist delivered the program, had the wording been altered to include physiotherapists or a more general term for healthcare professionals, we may have seen a change in these results.”
Dr. Janaudis-Ferreira and co-authors had no conflicts of interest to disclose. The study was funded by a grant from the Canadian Respiratory Health Professionals, which did not have input in research or manuscript development.
SOURCE: Janaudis-Ferreira T, et al. Chest
A brief patient-directed education program delivered at the time of hospitalization for an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) improved disease-specific knowledge, according to results of a pilot randomized trial.
Patients who participated in education sessions had a significant improvement in their scores on the Bristol COPD Knowledge Questionnaire (BCKQ), compared with control patients who received no education, study investigators reported in the journal Chest.
“Early education may be a bridge to more active approaches and could provide an important contribution to self-management interventions post-AECOPD,” wrote first author Tania Janaudis-Ferreira, PhD, of the School of Physical and Occupational Therapy, McGill University, Montreal, and her co-authors.
In the study, patients admitted to a community hospital with an AECOPD were randomized to standard care plus brief education or standard care alone. The education consisted of two 30-minute sessions delivered by a physiotherapist, either in the hospital or at home up to 2 weeks after the admission.
Before and after the intervention period, participant knowledge was measured using both the BCKQ and the Lung Information Needs Questionnaire (LINQ).
A total of 31 patients participated, including 15 in the intervention group and 16 in the control group, although 3 patients in the control group did not complete the follow-up testing, investigators said in their report.
The mean change in BCKQ was 8 points for the educational intervention group, and 3.4 for the control group (P = 0.02). That result was in keeping with findings of a previous randomized study noting an 8.3-point change in BCKQ scores for COPD patients who received education in the primary care setting, Dr. Janaudis-Ferreira and co-authors said.
“The change itself is relatively modest, suggesting more frequent sessions might result in greater improvements,” they wrote. For example, they said, an 8-week educational intervention delivered in the context of pulmonary rehabilitation program in one study yielded a mean change of 18.3 points on the BCKQ in the intervention group.
By contrast, the investigators found no significant difference in LINQ score changes between the intervention and control groups (P = .8).
That may indicate that two 30-minute sessions were not sufficient to attend to patients’ learning needs, authors said, though it could also have been an issue with the instrument itself in the setting of this study.
“The majority of the questions in the LINQ ask whether or not a doctor or nurse has explained a specific question to the patient,” authors explained. “Since a physiotherapist delivered the program, had the wording been altered to include physiotherapists or a more general term for healthcare professionals, we may have seen a change in these results.”
Dr. Janaudis-Ferreira and co-authors had no conflicts of interest to disclose. The study was funded by a grant from the Canadian Respiratory Health Professionals, which did not have input in research or manuscript development.
SOURCE: Janaudis-Ferreira T, et al. Chest
A brief patient-directed education program delivered at the time of hospitalization for an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) improved disease-specific knowledge, according to results of a pilot randomized trial.
Patients who participated in education sessions had a significant improvement in their scores on the Bristol COPD Knowledge Questionnaire (BCKQ), compared with control patients who received no education, study investigators reported in the journal Chest.
“Early education may be a bridge to more active approaches and could provide an important contribution to self-management interventions post-AECOPD,” wrote first author Tania Janaudis-Ferreira, PhD, of the School of Physical and Occupational Therapy, McGill University, Montreal, and her co-authors.
In the study, patients admitted to a community hospital with an AECOPD were randomized to standard care plus brief education or standard care alone. The education consisted of two 30-minute sessions delivered by a physiotherapist, either in the hospital or at home up to 2 weeks after the admission.
Before and after the intervention period, participant knowledge was measured using both the BCKQ and the Lung Information Needs Questionnaire (LINQ).
A total of 31 patients participated, including 15 in the intervention group and 16 in the control group, although 3 patients in the control group did not complete the follow-up testing, investigators said in their report.
The mean change in BCKQ was 8 points for the educational intervention group, and 3.4 for the control group (P = 0.02). That result was in keeping with findings of a previous randomized study noting an 8.3-point change in BCKQ scores for COPD patients who received education in the primary care setting, Dr. Janaudis-Ferreira and co-authors said.
“The change itself is relatively modest, suggesting more frequent sessions might result in greater improvements,” they wrote. For example, they said, an 8-week educational intervention delivered in the context of pulmonary rehabilitation program in one study yielded a mean change of 18.3 points on the BCKQ in the intervention group.
By contrast, the investigators found no significant difference in LINQ score changes between the intervention and control groups (P = .8).
That may indicate that two 30-minute sessions were not sufficient to attend to patients’ learning needs, authors said, though it could also have been an issue with the instrument itself in the setting of this study.
“The majority of the questions in the LINQ ask whether or not a doctor or nurse has explained a specific question to the patient,” authors explained. “Since a physiotherapist delivered the program, had the wording been altered to include physiotherapists or a more general term for healthcare professionals, we may have seen a change in these results.”
Dr. Janaudis-Ferreira and co-authors had no conflicts of interest to disclose. The study was funded by a grant from the Canadian Respiratory Health Professionals, which did not have input in research or manuscript development.
SOURCE: Janaudis-Ferreira T, et al. Chest
FROM CHEST
Key clinical point: Two 30-minute education sessions improved patients’ disease-specific knowledge for an acute exacerbation of COPD.
Major finding: Mean change on the Bristol COPD Knowledge Questionnaire (BCKQ) was 8 points for the educational intervention, and 3.4 for controls.
Study details: A pilot randomized controlled trial of 31 patients admitted to a community hospital.
Disclosures: Authors had no conflicts of interest to disclose. The study was funded by a grant from the Canadian Respiratory Health Professionals, which did not have input in research or manuscript development.
Source: Janaudis-Ferreira T, et al. Chest 2018 Jun 4.
Reducing the Risk of Overt Hepatic Encephalopathy (HE) Recurrence and HE-Related Hospitalizations
In this supplement to The Hospitalist, Dr. Hameed Ali discusses HE and the importance of identifying and properly managing this common complication of cirrhosis.
Topics include:
- The various stages of HE
- The burden of HE and hospital readmission rates
- A medication for overt HE management
About the Author:
Hameed Q. Ali, DO, FHM
Clinical Assistant Professor
Department of Internal Medicine
Texas A&M Health Science Center
Temple, TX
XIF.0097.USA.18
In this supplement to The Hospitalist, Dr. Hameed Ali discusses HE and the importance of identifying and properly managing this common complication of cirrhosis.
Topics include:
- The various stages of HE
- The burden of HE and hospital readmission rates
- A medication for overt HE management
About the Author:
Hameed Q. Ali, DO, FHM
Clinical Assistant Professor
Department of Internal Medicine
Texas A&M Health Science Center
Temple, TX
XIF.0097.USA.18
In this supplement to The Hospitalist, Dr. Hameed Ali discusses HE and the importance of identifying and properly managing this common complication of cirrhosis.
Topics include:
- The various stages of HE
- The burden of HE and hospital readmission rates
- A medication for overt HE management
About the Author:
Hameed Q. Ali, DO, FHM
Clinical Assistant Professor
Department of Internal Medicine
Texas A&M Health Science Center
Temple, TX
XIF.0097.USA.18
