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Hospitalist movers and shakers – Sept. 2017
Robert Harrington, MD, recently was tabbed as chief medical officer of SurveyVitals, a health care analytics company specializing in digital patient-experience surveys. Dr. Harrington has 20 years experience, including CMO roles with Reliant Post–Acute Care Solutions and Locum Leaders, a hospitalist staffing firm.
Dr. Harrington is a senior fellow in Hospital Medicine and is past president and member of the board of directors with the Society of Hospital Medicine.
David Northington, DO, has been named the new chief medical officer at Stone County Hospital in Wiggins, Miss. The former hospitalist comes to Stone County after working as chief of staff and chief medical information officer at Memorial Hospital in Gulfport, Miss., where he was also medical director of the hospitalist program.
In addition to his new role, Dr. Northington will serve as medical director of the Woodland Village Nursing Center in Diamondhead, Miss., and the Stone County Nursing and Rehabilitation Center in Wiggins.
Schuyler K. Geller, MD, has been recognized by Continental Who’s Who as a Pinnacle Lifetime Member in the medical field. Dr. Geller works as a full-time hospitalist and a principal consultant for The CopperRidge Group, which provides guidance to patients in health, wellness, and fitness services and products.
In addition to his work at the CopperRidge Group, Dr. Geller is a member of Civil Vision International’s board of directors. He has extensive civilian and military-based experience in the United States, Africa, the Middle East, and South Asia.
A physician leader in the U.S. Air Force, Dr. Geller earned White House Medical Unit commendations for planning and leading the surgical and intensive care unit teams to support President Clinton’s trips to Vietnam and Africa in 2000.
Nikhil Sharma, MD, recently was selected by the International Association of HealthCare Professionals to be part of the Leading Physicians of the World. Dr. Sharma is a hospitalist serving at the Ochsner Health System in New Orleans.
Dr. Sharma, a member of the Southern Hospital Association and the Louisiana Medical Association, began his medical career in 2009 with a residency and fellowship at Ochsner, where he has remained ever since. He specializes in internal medicine and transplants.
I. Carol Nwelue, MD, a longtime hospitalist and the medical director of the Sparrow Medical Group Adult Hospitalist Service, recently received the Sparrow Physician Leadership Award. The award goes to an emerging leader who provides outstanding work in areas such as safety, clinical or service excellence, research, teaching, publishing, teamwork, and innovation.
Dr. Nwelue completed the Sparrow Physician Leadership Academy program, earning recognition for innovation in leadership, as well as practice management.
Laura Jin, MD, recently was promoted to medical director for utilization management at the University of Maryland Shore Regional Health. In her new role, Dr. Jin will identify and facilitate the resolution of utilization issues; in so doing, she will serve as a consultant leader to the health care system, its physicians, its advance practice providers, and the care management team.
Dr. Jin will remain as a hospitalist at Digestive Health Associates while fulfilling the duties in her new position at Shore Regional. She will guide the center on issues such as compliance, level of care, length of stay, resource management, reimbursement, emergency department throughput, and more.
Business Moves
The Mount Sinai Health System and The New Jewish Home, both based in New York City, have extended their relationship to improve care of hospitalized patients who require specialized post-acute or long-term care at a skilled nursing facility. Through the Mount Sinai-New Jewish Home Hospitalist Program, Mount Sinai hospitalists will be charged with providing a seamless transition to The New Jewish Home for patients who need nursing care.
This model will buoy communication and ensure the sharing of vital information between the two venues, reducing the risk of rehospitalization.
Gryphon Investors, based in San Francisco, recently announced it will acquire OB Hospitalist Group, one of the nation’s leading providers of obstetric hospital medicine. The deal with OBHG’s current partner, Ares Management, was finalized in late July.
OBHG, based out of Mauldin, S.C., has a national network of more than 550 OB hospitalists, covering more than 120 hospitals in 28 states. OBHG’s hospitalist program features an obstetric emergency department, providing expectant mothers at partner hospitals with 24/7/365 access to medical care.
Envision Healthcare, based in Nashville, Tenn., and Greenwood Village, Colo., a provider of physician-led services and ambulatory surgery services, has acquired Milwaukee-based Infinity Healthcare. Infinity’s group-physician practice includes more than 340 physicians and providers delivering emergency and hospital medicine, anesthesia, and radiology services.
Robert Harrington, MD, recently was tabbed as chief medical officer of SurveyVitals, a health care analytics company specializing in digital patient-experience surveys. Dr. Harrington has 20 years experience, including CMO roles with Reliant Post–Acute Care Solutions and Locum Leaders, a hospitalist staffing firm.
Dr. Harrington is a senior fellow in Hospital Medicine and is past president and member of the board of directors with the Society of Hospital Medicine.
David Northington, DO, has been named the new chief medical officer at Stone County Hospital in Wiggins, Miss. The former hospitalist comes to Stone County after working as chief of staff and chief medical information officer at Memorial Hospital in Gulfport, Miss., where he was also medical director of the hospitalist program.
In addition to his new role, Dr. Northington will serve as medical director of the Woodland Village Nursing Center in Diamondhead, Miss., and the Stone County Nursing and Rehabilitation Center in Wiggins.
Schuyler K. Geller, MD, has been recognized by Continental Who’s Who as a Pinnacle Lifetime Member in the medical field. Dr. Geller works as a full-time hospitalist and a principal consultant for The CopperRidge Group, which provides guidance to patients in health, wellness, and fitness services and products.
In addition to his work at the CopperRidge Group, Dr. Geller is a member of Civil Vision International’s board of directors. He has extensive civilian and military-based experience in the United States, Africa, the Middle East, and South Asia.
A physician leader in the U.S. Air Force, Dr. Geller earned White House Medical Unit commendations for planning and leading the surgical and intensive care unit teams to support President Clinton’s trips to Vietnam and Africa in 2000.
Nikhil Sharma, MD, recently was selected by the International Association of HealthCare Professionals to be part of the Leading Physicians of the World. Dr. Sharma is a hospitalist serving at the Ochsner Health System in New Orleans.
Dr. Sharma, a member of the Southern Hospital Association and the Louisiana Medical Association, began his medical career in 2009 with a residency and fellowship at Ochsner, where he has remained ever since. He specializes in internal medicine and transplants.
I. Carol Nwelue, MD, a longtime hospitalist and the medical director of the Sparrow Medical Group Adult Hospitalist Service, recently received the Sparrow Physician Leadership Award. The award goes to an emerging leader who provides outstanding work in areas such as safety, clinical or service excellence, research, teaching, publishing, teamwork, and innovation.
Dr. Nwelue completed the Sparrow Physician Leadership Academy program, earning recognition for innovation in leadership, as well as practice management.
Laura Jin, MD, recently was promoted to medical director for utilization management at the University of Maryland Shore Regional Health. In her new role, Dr. Jin will identify and facilitate the resolution of utilization issues; in so doing, she will serve as a consultant leader to the health care system, its physicians, its advance practice providers, and the care management team.
Dr. Jin will remain as a hospitalist at Digestive Health Associates while fulfilling the duties in her new position at Shore Regional. She will guide the center on issues such as compliance, level of care, length of stay, resource management, reimbursement, emergency department throughput, and more.
Business Moves
The Mount Sinai Health System and The New Jewish Home, both based in New York City, have extended their relationship to improve care of hospitalized patients who require specialized post-acute or long-term care at a skilled nursing facility. Through the Mount Sinai-New Jewish Home Hospitalist Program, Mount Sinai hospitalists will be charged with providing a seamless transition to The New Jewish Home for patients who need nursing care.
This model will buoy communication and ensure the sharing of vital information between the two venues, reducing the risk of rehospitalization.
Gryphon Investors, based in San Francisco, recently announced it will acquire OB Hospitalist Group, one of the nation’s leading providers of obstetric hospital medicine. The deal with OBHG’s current partner, Ares Management, was finalized in late July.
OBHG, based out of Mauldin, S.C., has a national network of more than 550 OB hospitalists, covering more than 120 hospitals in 28 states. OBHG’s hospitalist program features an obstetric emergency department, providing expectant mothers at partner hospitals with 24/7/365 access to medical care.
Envision Healthcare, based in Nashville, Tenn., and Greenwood Village, Colo., a provider of physician-led services and ambulatory surgery services, has acquired Milwaukee-based Infinity Healthcare. Infinity’s group-physician practice includes more than 340 physicians and providers delivering emergency and hospital medicine, anesthesia, and radiology services.
Robert Harrington, MD, recently was tabbed as chief medical officer of SurveyVitals, a health care analytics company specializing in digital patient-experience surveys. Dr. Harrington has 20 years experience, including CMO roles with Reliant Post–Acute Care Solutions and Locum Leaders, a hospitalist staffing firm.
Dr. Harrington is a senior fellow in Hospital Medicine and is past president and member of the board of directors with the Society of Hospital Medicine.
David Northington, DO, has been named the new chief medical officer at Stone County Hospital in Wiggins, Miss. The former hospitalist comes to Stone County after working as chief of staff and chief medical information officer at Memorial Hospital in Gulfport, Miss., where he was also medical director of the hospitalist program.
In addition to his new role, Dr. Northington will serve as medical director of the Woodland Village Nursing Center in Diamondhead, Miss., and the Stone County Nursing and Rehabilitation Center in Wiggins.
Schuyler K. Geller, MD, has been recognized by Continental Who’s Who as a Pinnacle Lifetime Member in the medical field. Dr. Geller works as a full-time hospitalist and a principal consultant for The CopperRidge Group, which provides guidance to patients in health, wellness, and fitness services and products.
In addition to his work at the CopperRidge Group, Dr. Geller is a member of Civil Vision International’s board of directors. He has extensive civilian and military-based experience in the United States, Africa, the Middle East, and South Asia.
A physician leader in the U.S. Air Force, Dr. Geller earned White House Medical Unit commendations for planning and leading the surgical and intensive care unit teams to support President Clinton’s trips to Vietnam and Africa in 2000.
Nikhil Sharma, MD, recently was selected by the International Association of HealthCare Professionals to be part of the Leading Physicians of the World. Dr. Sharma is a hospitalist serving at the Ochsner Health System in New Orleans.
Dr. Sharma, a member of the Southern Hospital Association and the Louisiana Medical Association, began his medical career in 2009 with a residency and fellowship at Ochsner, where he has remained ever since. He specializes in internal medicine and transplants.
I. Carol Nwelue, MD, a longtime hospitalist and the medical director of the Sparrow Medical Group Adult Hospitalist Service, recently received the Sparrow Physician Leadership Award. The award goes to an emerging leader who provides outstanding work in areas such as safety, clinical or service excellence, research, teaching, publishing, teamwork, and innovation.
Dr. Nwelue completed the Sparrow Physician Leadership Academy program, earning recognition for innovation in leadership, as well as practice management.
Laura Jin, MD, recently was promoted to medical director for utilization management at the University of Maryland Shore Regional Health. In her new role, Dr. Jin will identify and facilitate the resolution of utilization issues; in so doing, she will serve as a consultant leader to the health care system, its physicians, its advance practice providers, and the care management team.
Dr. Jin will remain as a hospitalist at Digestive Health Associates while fulfilling the duties in her new position at Shore Regional. She will guide the center on issues such as compliance, level of care, length of stay, resource management, reimbursement, emergency department throughput, and more.
Business Moves
The Mount Sinai Health System and The New Jewish Home, both based in New York City, have extended their relationship to improve care of hospitalized patients who require specialized post-acute or long-term care at a skilled nursing facility. Through the Mount Sinai-New Jewish Home Hospitalist Program, Mount Sinai hospitalists will be charged with providing a seamless transition to The New Jewish Home for patients who need nursing care.
This model will buoy communication and ensure the sharing of vital information between the two venues, reducing the risk of rehospitalization.
Gryphon Investors, based in San Francisco, recently announced it will acquire OB Hospitalist Group, one of the nation’s leading providers of obstetric hospital medicine. The deal with OBHG’s current partner, Ares Management, was finalized in late July.
OBHG, based out of Mauldin, S.C., has a national network of more than 550 OB hospitalists, covering more than 120 hospitals in 28 states. OBHG’s hospitalist program features an obstetric emergency department, providing expectant mothers at partner hospitals with 24/7/365 access to medical care.
Envision Healthcare, based in Nashville, Tenn., and Greenwood Village, Colo., a provider of physician-led services and ambulatory surgery services, has acquired Milwaukee-based Infinity Healthcare. Infinity’s group-physician practice includes more than 340 physicians and providers delivering emergency and hospital medicine, anesthesia, and radiology services.
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Onecount Call To Arms
How hospitalists can help reduce readmissions
Hospital readmissions are frequent, harmful, and costly. Consider the fact that 18% of Medicare patients can expect to be readmitted within 30 days at a cost of more than $17 billion.1 Recent changes in health care policy aimed at reducing readmission have substantially increased attention to this major health care issue.2
The Affordable Care Act has mandated that the Centers for Medicare & Medicaid Services reduce payment to hospitals with higher-than-expected 30-day readmissions, with its Hospital Readmissions Reduction Program. This has driven rapid growth in the study of patients rehospitalized within 30 days of discharge.3 So what are some strategies that have either been proven to reduce readmissions or show promise in doing so? 
An ounce of prevention
In studying inpatient and outpatient physicians’ perspectives regarding factors contributing to readmission,4 Shoshana Herzig, MD, MPH, assistant professor of medicine, Harvard Medical School, and director of Hospital Medicine Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, and her colleagues identified some potential preventive strategies.
The most commonly endorsed strategy to prevent readmissions by both primary care physicians and hospitalists surveyed involved improving self-management plans at discharge. “This refers to actions such as providing patient-centered discharge instructions (that is, making sure they are written in language that patients can understand) or asking transition coaches to help facilitate a successful transition,” Dr. Herzig said. “This finding is consistent with the fact that the factor most commonly identified as contributing to readmissions was insufficient patient understanding or ability to self-manage. Combined, these findings suggest that strategies to enhance patient understanding of their illness, care plan, and what to expect after hospital discharge, are likely to be important components of successful readmission reduction programs.”
Provisioning of resources to patients to help them manage their care after discharge is also recommended. For example, engaging nurses or pharmacists who can help with issues that arise after discharge may help keep patients out of the hospital.
“Hospitalists should be aware of what resources are available to help patients manage their care,” Dr. Herzig said. For example, if a patient needs periodic blood pressure monitoring, the hospitalist can tell the patient about free blood pressure checkpoints or suggest a home-automated blood pressure monitor.
The study also showed that improved coordination of care between inpatient and outpatient providers, such as sharing medical records, could reduce readmission rates. “This allows for better inpatient care and increased ability for primary care physicians to react appropriately to issues arising after discharge,” Dr. Herzig said. “In the absence of a shared system, hospitalists should complete discharge summaries in a timely fashion and ensure that they’re promptly transmitted to primary care physicians.”
Dr. Herzig said it’s important to note that hospitalists and primary care physicians had different appraisals of reasons for readmission. Therefore, when designing readmission reduction programs or determining specific services to prevent a readmission for a given patient, it is important for hospitalists to obtain input from primary care physicians to ensure that they address all of the potential contributors to readmission for a given patient.
Interviewing patients regarding readmissions
After involved clinicians and independent physician reviewers performed extensive case reviews of more than 700 readmitted patients,6 Ashley Busuttil, MD, FHM, associate section chief, Hospital Medicine, University of California, Los Angeles Department of Medicine; and executive medical director, Medicine Services, UCLA Department of Medicine, and Erin Dowling, MD, assistant clinical professor, General Internal Medicine, Hospitalist Services, UCLA Medical Center, Santa Monica, Calif., and their colleagues were unable to identify which readmissions could have easily been prevented, and found that readmission causality varied extensively.
Through interviews with patients, the researchers determined that patients were more likely to think that their readmission was preventable if they felt unready for discharge during their initial hospitalization. This was despite the fact that patients met what clinicians would consider “ready” by objective, provider-centric criteria: they were medically stable, they had in-home support services, they had follow-up arranged, and so forth. As such, they wanted to put effort into educating and preparing patients for what home will look and feel like posthospitalization to address their feelings of unreadiness.
To that end, the researchers created an enhanced transition initiative that included showing an educational video near the time of admission and a patient-centered discharge checklist to help patients identify questions they might have after discharge. The discharge checklist asks patients to put themselves in the position of being at home and working through scenarios they may face so they will know how to deal with them. For example, if you have pain, who should you call? What should you do if you run out of medication?
Dr. Dowling believes that the hospitalist will, over time, become essential to assessing patient readiness. “As we learn more about how patients approach discharge, hospitalists’ understanding of patient needs beyond straightforward medical care will be crucial to having smoother transitions of care,” she said.
The researchers also explored pain control. As a health system, UCLA Medical Center has formed a multidisciplinary task force to optimize its approach to pain control. “If we can address comfort – for both patients at high risk of readmission and those that aren’t – we hope we can improve symptom control overall,” Dr. Busuttil said. “It’s not uncommon for patients to feel inadequate symptom control at discharge. While this is likely only one component of all the readmission pieces, a patient who feels that their symptoms are not controlled is likely to feel less ready for discharge. Increasing patient readiness, perhaps by increasing symptom control and improving communication regarding symptom management expectations, is a task that the hospitalist is well positioned to address.”
The researchers also wanted to find out why patients may not use available outpatient resources, and assessed them for decisional conflict – a measure of certainty with decision making – when selecting from multiple options for accessing medical care if they were home postdischarge and began to feel ill again. “Patients with decisional conflict were more likely to state that they would go the emergency room rather than call their primary medical physician or visit an urgent care center,” Dr. Busuttil said.
The health system continues to screen patients for decisional conflict. “When positive, we provide bedside education on when to seek medical care through primary care, urgent care, or the emergency department,” Dr. Busuttil said. “We also provide patients with information on how to access each of these resources.”
While a prior discharge plan may have seemed ideal on paper, time and time again it’s not logistically possible for certain patients. “By having this knowledge gleaned from patient interviews, hospitalists are able to provide feedback to health systems regarding different options of outpatient care that may work for the different patient populations they serve,” Dr. Dowling said.
To understand why one particular patient population is being readmitted requires taking the time to understand that population, Dr. Dowling noted. “While many validated risk stratification tools are available, they may only serve as general guides,” she said. “To impact the population you serve, you must first understand the readmission process as it looks to them.”
Employing the HOSPITAL score
In another effort to reduce hospital readmissions, Jacques Donzé, MD, MSc, associate physician, Bern University Hospital, Switzerland, and research associate, Brigham and Women’s Hospital, Boston, and his colleagues used the HOSPITAL score to identify patients at high risk of 30-day potentially avoidable readmission.
To most efficiently reduce hospital readmissions, hospitals need to target complex and intensive discharge interventions for patients at high risk of potentially avoidable readmission who are more likely to benefit.2 “However, prior research indicates that clinical health care providers are not able to accurately identify which patients are at high risk for readmission,” Dr. Donzé said.
Dr. Donzé believes that several factors may influence the performance of a prediction model, such as the initial selection of the potential predictors, the quality of the derivation method, including readily available predictors commonly available, and including reliable factors that aren’t subject to subjective evaluation. “All of these factors can play a role in the performance and generalizability of the HOSPITAL score,” he said.
When a patient is identified as high risk to be readmitted, hospitalists can take certain actions to prevent readmission. “Interventions are more likely to be effective when they include several components,” Dr. Donzé said. “These include follow-up phone calls and/or home visits, review of the patient’s medication list, patient education, and sending a discharge summary to the patient’s primary care physician in a timely manner. For now, enough evidence for a specific effective multimodal intervention to be generalizable to the majority of patients is lacking.”
Currently, the HOSPITAL score has been validated in approximately 180,000 patients in 14 hospitals across five countries and three continents – always showing good performance and generalizability. The HOSPITAL score includes seven variables readily available before hospital discharge, is easy to use, and is the most widely validated prediction model for readmission, Dr. Donzé said.
Before being implemented into practice, a score should ideally reach the highest level of validation, that is, show its clinical impact. “We expect that the score will not only be able to accurately predict high-risk patients, but using the score will also impact patient care by reducing readmissions when coupled with an appropriate intervention,” Dr. Donzé said.
In summary, research has shown that a variety of methods can be used to reduce hospital readmissions, including studying inpatient and outpatient physicians’ perspectives regarding factors contributing to readmission; interviewing patients regarding readmissions; and identifying patients at high risk of readmission using the HOSPITAL score.
Many researchers are continuing their studies in these areas.
Karen Appold is a medical writer in Pennsylvania.
Using hospitalist reflections as a means to reduce readmissions
Readmission studies and the development of readmission scoring systems and prediction tools rely on data from a large number of patients, typically extracted from administrative databases.
To complement this data, Deanne Kashiwagi, MD, consultant, Hospital Internal Medicine, Mayo Clinic, Rochester, Minn., and her colleagues asked hospitalists to reflect upon the readmissions of patients for whom they cared to add insight into the culture of patient care transitions within the health system.
“We felt there was some value in considering these nuances of the local care environment, which may not be represented in studies drawing from large databases, as potential targets for readmission efforts,” she said.
Dr. Kashiwagi believes that including elements of local practice and culture was the strength of their work. “Groups interested in replicating this reflective process should consider including factors specific to their practices that may contribute to readmission,” she said.
Asking hospitalists to perform reviews has led to implementing changes. Physicians were prompted to schedule earlier follow-up appointments and nurse practitioners and physician assistants have worked to improve the quality of their discharge summaries. The exercise also engaged hospitalists to suggest system changes that might contribute to decreased readmissions, such as a geriatrician-run service (which was recently begun) to provide multidisciplinary acute geriatric care for hospitalized older adults.
“Although large-scale studies are clearly important, readmission review at a more granular level may have merit as well,” Dr. Kashiwagi said, noting that such reviews identify local practice factors that groups may quickly act upon to help decrease readmissions. “Hospitalists readily engaged in this reflective exercise, which yielded actionable information to decrease readmissions.”
In commenting on why a different similar study7 didn’t mimic the results of Mayo Clinic’s study, Dr. Kashiwagi said there were some differences in methodology that may explain the difference in readmission rates. “First, this group excluded patients on dialysis, which in our study was a common comorbidity of our readmitted patients,” she said. “It is also notable that the chart review tool was different. Perhaps there is less representation of local factors, unique to that hospitalist group and their practice culture, than on our review form. These investigators also discussed their readmissions at routine intervals. Additionally, their preintervention readmission rate was lower than Mayo Clinic’s group, and although the readmission rate trended downward postintervention, it did not reach statistical significance.”
References
1. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-28.
2. Donzé JD, Williams MV, Robinson EJ, et al. International validity of the HOSPITAL Score to predict 30-day potentially avoidable hospital readmissions. JAMA Intern Med. 2016 Apr;176(4):496-502.
3. Kashiwagi DT, Burton MC, Hakim FA, et al. Reflective practice: a tool for readmission reduction. Am J Med Qual. 2016 May;31(3):265-71.
4. Herzig SJ, Schnipper JL, Doctoroff L, et al. Physician perspectives on factors contributing to readmissions and potential prevention strategies: a multicenter survey. J Gen Intern Med. 2016 Nov;31(11):1287-93. Epub 2016 Jun 9.
5. Allaudeen N, Schnipper JL, Orav EJ, et al. Inability of providers to predict unplanned readmissions. J Gen Intern Med. 2011 Jul;26(7):771-6.
6. Busuttil A, Howard-Anderson J, Dowling EP, et al. Building a comprehensive patient-centered readmission reduction program [abstract]. J Hosp Med. 2016;11(suppl 1).
7. Rana V, Thapa B, Saini SC, et al. Self-reflection as a tool to increase hospitalist participation in readmission quality improvement. Qual Manag Health Care. 2016 Oct/Dec;25(4):219-24.
Hospital readmissions are frequent, harmful, and costly. Consider the fact that 18% of Medicare patients can expect to be readmitted within 30 days at a cost of more than $17 billion.1 Recent changes in health care policy aimed at reducing readmission have substantially increased attention to this major health care issue.2
The Affordable Care Act has mandated that the Centers for Medicare & Medicaid Services reduce payment to hospitals with higher-than-expected 30-day readmissions, with its Hospital Readmissions Reduction Program. This has driven rapid growth in the study of patients rehospitalized within 30 days of discharge.3 So what are some strategies that have either been proven to reduce readmissions or show promise in doing so?
An ounce of prevention
In studying inpatient and outpatient physicians’ perspectives regarding factors contributing to readmission,4 Shoshana Herzig, MD, MPH, assistant professor of medicine, Harvard Medical School, and director of Hospital Medicine Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, and her colleagues identified some potential preventive strategies.
The most commonly endorsed strategy to prevent readmissions by both primary care physicians and hospitalists surveyed involved improving self-management plans at discharge. “This refers to actions such as providing patient-centered discharge instructions (that is, making sure they are written in language that patients can understand) or asking transition coaches to help facilitate a successful transition,” Dr. Herzig said. “This finding is consistent with the fact that the factor most commonly identified as contributing to readmissions was insufficient patient understanding or ability to self-manage. Combined, these findings suggest that strategies to enhance patient understanding of their illness, care plan, and what to expect after hospital discharge, are likely to be important components of successful readmission reduction programs.”
Provisioning of resources to patients to help them manage their care after discharge is also recommended. For example, engaging nurses or pharmacists who can help with issues that arise after discharge may help keep patients out of the hospital.
“Hospitalists should be aware of what resources are available to help patients manage their care,” Dr. Herzig said. For example, if a patient needs periodic blood pressure monitoring, the hospitalist can tell the patient about free blood pressure checkpoints or suggest a home-automated blood pressure monitor.
The study also showed that improved coordination of care between inpatient and outpatient providers, such as sharing medical records, could reduce readmission rates. “This allows for better inpatient care and increased ability for primary care physicians to react appropriately to issues arising after discharge,” Dr. Herzig said. “In the absence of a shared system, hospitalists should complete discharge summaries in a timely fashion and ensure that they’re promptly transmitted to primary care physicians.”
Dr. Herzig said it’s important to note that hospitalists and primary care physicians had different appraisals of reasons for readmission. Therefore, when designing readmission reduction programs or determining specific services to prevent a readmission for a given patient, it is important for hospitalists to obtain input from primary care physicians to ensure that they address all of the potential contributors to readmission for a given patient.
Interviewing patients regarding readmissions
After involved clinicians and independent physician reviewers performed extensive case reviews of more than 700 readmitted patients,6 Ashley Busuttil, MD, FHM, associate section chief, Hospital Medicine, University of California, Los Angeles Department of Medicine; and executive medical director, Medicine Services, UCLA Department of Medicine, and Erin Dowling, MD, assistant clinical professor, General Internal Medicine, Hospitalist Services, UCLA Medical Center, Santa Monica, Calif., and their colleagues were unable to identify which readmissions could have easily been prevented, and found that readmission causality varied extensively.
Through interviews with patients, the researchers determined that patients were more likely to think that their readmission was preventable if they felt unready for discharge during their initial hospitalization. This was despite the fact that patients met what clinicians would consider “ready” by objective, provider-centric criteria: they were medically stable, they had in-home support services, they had follow-up arranged, and so forth. As such, they wanted to put effort into educating and preparing patients for what home will look and feel like posthospitalization to address their feelings of unreadiness.
To that end, the researchers created an enhanced transition initiative that included showing an educational video near the time of admission and a patient-centered discharge checklist to help patients identify questions they might have after discharge. The discharge checklist asks patients to put themselves in the position of being at home and working through scenarios they may face so they will know how to deal with them. For example, if you have pain, who should you call? What should you do if you run out of medication?
Dr. Dowling believes that the hospitalist will, over time, become essential to assessing patient readiness. “As we learn more about how patients approach discharge, hospitalists’ understanding of patient needs beyond straightforward medical care will be crucial to having smoother transitions of care,” she said.
The researchers also explored pain control. As a health system, UCLA Medical Center has formed a multidisciplinary task force to optimize its approach to pain control. “If we can address comfort – for both patients at high risk of readmission and those that aren’t – we hope we can improve symptom control overall,” Dr. Busuttil said. “It’s not uncommon for patients to feel inadequate symptom control at discharge. While this is likely only one component of all the readmission pieces, a patient who feels that their symptoms are not controlled is likely to feel less ready for discharge. Increasing patient readiness, perhaps by increasing symptom control and improving communication regarding symptom management expectations, is a task that the hospitalist is well positioned to address.”
The researchers also wanted to find out why patients may not use available outpatient resources, and assessed them for decisional conflict – a measure of certainty with decision making – when selecting from multiple options for accessing medical care if they were home postdischarge and began to feel ill again. “Patients with decisional conflict were more likely to state that they would go the emergency room rather than call their primary medical physician or visit an urgent care center,” Dr. Busuttil said.
The health system continues to screen patients for decisional conflict. “When positive, we provide bedside education on when to seek medical care through primary care, urgent care, or the emergency department,” Dr. Busuttil said. “We also provide patients with information on how to access each of these resources.”
While a prior discharge plan may have seemed ideal on paper, time and time again it’s not logistically possible for certain patients. “By having this knowledge gleaned from patient interviews, hospitalists are able to provide feedback to health systems regarding different options of outpatient care that may work for the different patient populations they serve,” Dr. Dowling said.
To understand why one particular patient population is being readmitted requires taking the time to understand that population, Dr. Dowling noted. “While many validated risk stratification tools are available, they may only serve as general guides,” she said. “To impact the population you serve, you must first understand the readmission process as it looks to them.”
Employing the HOSPITAL score
In another effort to reduce hospital readmissions, Jacques Donzé, MD, MSc, associate physician, Bern University Hospital, Switzerland, and research associate, Brigham and Women’s Hospital, Boston, and his colleagues used the HOSPITAL score to identify patients at high risk of 30-day potentially avoidable readmission.
To most efficiently reduce hospital readmissions, hospitals need to target complex and intensive discharge interventions for patients at high risk of potentially avoidable readmission who are more likely to benefit.2 “However, prior research indicates that clinical health care providers are not able to accurately identify which patients are at high risk for readmission,” Dr. Donzé said.
Dr. Donzé believes that several factors may influence the performance of a prediction model, such as the initial selection of the potential predictors, the quality of the derivation method, including readily available predictors commonly available, and including reliable factors that aren’t subject to subjective evaluation. “All of these factors can play a role in the performance and generalizability of the HOSPITAL score,” he said.
When a patient is identified as high risk to be readmitted, hospitalists can take certain actions to prevent readmission. “Interventions are more likely to be effective when they include several components,” Dr. Donzé said. “These include follow-up phone calls and/or home visits, review of the patient’s medication list, patient education, and sending a discharge summary to the patient’s primary care physician in a timely manner. For now, enough evidence for a specific effective multimodal intervention to be generalizable to the majority of patients is lacking.”
Currently, the HOSPITAL score has been validated in approximately 180,000 patients in 14 hospitals across five countries and three continents – always showing good performance and generalizability. The HOSPITAL score includes seven variables readily available before hospital discharge, is easy to use, and is the most widely validated prediction model for readmission, Dr. Donzé said.
Before being implemented into practice, a score should ideally reach the highest level of validation, that is, show its clinical impact. “We expect that the score will not only be able to accurately predict high-risk patients, but using the score will also impact patient care by reducing readmissions when coupled with an appropriate intervention,” Dr. Donzé said.
In summary, research has shown that a variety of methods can be used to reduce hospital readmissions, including studying inpatient and outpatient physicians’ perspectives regarding factors contributing to readmission; interviewing patients regarding readmissions; and identifying patients at high risk of readmission using the HOSPITAL score.
Many researchers are continuing their studies in these areas.
Karen Appold is a medical writer in Pennsylvania.
Using hospitalist reflections as a means to reduce readmissions
Readmission studies and the development of readmission scoring systems and prediction tools rely on data from a large number of patients, typically extracted from administrative databases.
To complement this data, Deanne Kashiwagi, MD, consultant, Hospital Internal Medicine, Mayo Clinic, Rochester, Minn., and her colleagues asked hospitalists to reflect upon the readmissions of patients for whom they cared to add insight into the culture of patient care transitions within the health system.
“We felt there was some value in considering these nuances of the local care environment, which may not be represented in studies drawing from large databases, as potential targets for readmission efforts,” she said.
Dr. Kashiwagi believes that including elements of local practice and culture was the strength of their work. “Groups interested in replicating this reflective process should consider including factors specific to their practices that may contribute to readmission,” she said.
Asking hospitalists to perform reviews has led to implementing changes. Physicians were prompted to schedule earlier follow-up appointments and nurse practitioners and physician assistants have worked to improve the quality of their discharge summaries. The exercise also engaged hospitalists to suggest system changes that might contribute to decreased readmissions, such as a geriatrician-run service (which was recently begun) to provide multidisciplinary acute geriatric care for hospitalized older adults.
“Although large-scale studies are clearly important, readmission review at a more granular level may have merit as well,” Dr. Kashiwagi said, noting that such reviews identify local practice factors that groups may quickly act upon to help decrease readmissions. “Hospitalists readily engaged in this reflective exercise, which yielded actionable information to decrease readmissions.”
In commenting on why a different similar study7 didn’t mimic the results of Mayo Clinic’s study, Dr. Kashiwagi said there were some differences in methodology that may explain the difference in readmission rates. “First, this group excluded patients on dialysis, which in our study was a common comorbidity of our readmitted patients,” she said. “It is also notable that the chart review tool was different. Perhaps there is less representation of local factors, unique to that hospitalist group and their practice culture, than on our review form. These investigators also discussed their readmissions at routine intervals. Additionally, their preintervention readmission rate was lower than Mayo Clinic’s group, and although the readmission rate trended downward postintervention, it did not reach statistical significance.”
References
1. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-28.
2. Donzé JD, Williams MV, Robinson EJ, et al. International validity of the HOSPITAL Score to predict 30-day potentially avoidable hospital readmissions. JAMA Intern Med. 2016 Apr;176(4):496-502.
3. Kashiwagi DT, Burton MC, Hakim FA, et al. Reflective practice: a tool for readmission reduction. Am J Med Qual. 2016 May;31(3):265-71.
4. Herzig SJ, Schnipper JL, Doctoroff L, et al. Physician perspectives on factors contributing to readmissions and potential prevention strategies: a multicenter survey. J Gen Intern Med. 2016 Nov;31(11):1287-93. Epub 2016 Jun 9.
5. Allaudeen N, Schnipper JL, Orav EJ, et al. Inability of providers to predict unplanned readmissions. J Gen Intern Med. 2011 Jul;26(7):771-6.
6. Busuttil A, Howard-Anderson J, Dowling EP, et al. Building a comprehensive patient-centered readmission reduction program [abstract]. J Hosp Med. 2016;11(suppl 1).
7. Rana V, Thapa B, Saini SC, et al. Self-reflection as a tool to increase hospitalist participation in readmission quality improvement. Qual Manag Health Care. 2016 Oct/Dec;25(4):219-24.
Hospital readmissions are frequent, harmful, and costly. Consider the fact that 18% of Medicare patients can expect to be readmitted within 30 days at a cost of more than $17 billion.1 Recent changes in health care policy aimed at reducing readmission have substantially increased attention to this major health care issue.2
The Affordable Care Act has mandated that the Centers for Medicare & Medicaid Services reduce payment to hospitals with higher-than-expected 30-day readmissions, with its Hospital Readmissions Reduction Program. This has driven rapid growth in the study of patients rehospitalized within 30 days of discharge.3 So what are some strategies that have either been proven to reduce readmissions or show promise in doing so?
An ounce of prevention
In studying inpatient and outpatient physicians’ perspectives regarding factors contributing to readmission,4 Shoshana Herzig, MD, MPH, assistant professor of medicine, Harvard Medical School, and director of Hospital Medicine Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, and her colleagues identified some potential preventive strategies.
The most commonly endorsed strategy to prevent readmissions by both primary care physicians and hospitalists surveyed involved improving self-management plans at discharge. “This refers to actions such as providing patient-centered discharge instructions (that is, making sure they are written in language that patients can understand) or asking transition coaches to help facilitate a successful transition,” Dr. Herzig said. “This finding is consistent with the fact that the factor most commonly identified as contributing to readmissions was insufficient patient understanding or ability to self-manage. Combined, these findings suggest that strategies to enhance patient understanding of their illness, care plan, and what to expect after hospital discharge, are likely to be important components of successful readmission reduction programs.”
Provisioning of resources to patients to help them manage their care after discharge is also recommended. For example, engaging nurses or pharmacists who can help with issues that arise after discharge may help keep patients out of the hospital.
“Hospitalists should be aware of what resources are available to help patients manage their care,” Dr. Herzig said. For example, if a patient needs periodic blood pressure monitoring, the hospitalist can tell the patient about free blood pressure checkpoints or suggest a home-automated blood pressure monitor.
The study also showed that improved coordination of care between inpatient and outpatient providers, such as sharing medical records, could reduce readmission rates. “This allows for better inpatient care and increased ability for primary care physicians to react appropriately to issues arising after discharge,” Dr. Herzig said. “In the absence of a shared system, hospitalists should complete discharge summaries in a timely fashion and ensure that they’re promptly transmitted to primary care physicians.”
Dr. Herzig said it’s important to note that hospitalists and primary care physicians had different appraisals of reasons for readmission. Therefore, when designing readmission reduction programs or determining specific services to prevent a readmission for a given patient, it is important for hospitalists to obtain input from primary care physicians to ensure that they address all of the potential contributors to readmission for a given patient.
Interviewing patients regarding readmissions
After involved clinicians and independent physician reviewers performed extensive case reviews of more than 700 readmitted patients,6 Ashley Busuttil, MD, FHM, associate section chief, Hospital Medicine, University of California, Los Angeles Department of Medicine; and executive medical director, Medicine Services, UCLA Department of Medicine, and Erin Dowling, MD, assistant clinical professor, General Internal Medicine, Hospitalist Services, UCLA Medical Center, Santa Monica, Calif., and their colleagues were unable to identify which readmissions could have easily been prevented, and found that readmission causality varied extensively.
Through interviews with patients, the researchers determined that patients were more likely to think that their readmission was preventable if they felt unready for discharge during their initial hospitalization. This was despite the fact that patients met what clinicians would consider “ready” by objective, provider-centric criteria: they were medically stable, they had in-home support services, they had follow-up arranged, and so forth. As such, they wanted to put effort into educating and preparing patients for what home will look and feel like posthospitalization to address their feelings of unreadiness.
To that end, the researchers created an enhanced transition initiative that included showing an educational video near the time of admission and a patient-centered discharge checklist to help patients identify questions they might have after discharge. The discharge checklist asks patients to put themselves in the position of being at home and working through scenarios they may face so they will know how to deal with them. For example, if you have pain, who should you call? What should you do if you run out of medication?
Dr. Dowling believes that the hospitalist will, over time, become essential to assessing patient readiness. “As we learn more about how patients approach discharge, hospitalists’ understanding of patient needs beyond straightforward medical care will be crucial to having smoother transitions of care,” she said.
The researchers also explored pain control. As a health system, UCLA Medical Center has formed a multidisciplinary task force to optimize its approach to pain control. “If we can address comfort – for both patients at high risk of readmission and those that aren’t – we hope we can improve symptom control overall,” Dr. Busuttil said. “It’s not uncommon for patients to feel inadequate symptom control at discharge. While this is likely only one component of all the readmission pieces, a patient who feels that their symptoms are not controlled is likely to feel less ready for discharge. Increasing patient readiness, perhaps by increasing symptom control and improving communication regarding symptom management expectations, is a task that the hospitalist is well positioned to address.”
The researchers also wanted to find out why patients may not use available outpatient resources, and assessed them for decisional conflict – a measure of certainty with decision making – when selecting from multiple options for accessing medical care if they were home postdischarge and began to feel ill again. “Patients with decisional conflict were more likely to state that they would go the emergency room rather than call their primary medical physician or visit an urgent care center,” Dr. Busuttil said.
The health system continues to screen patients for decisional conflict. “When positive, we provide bedside education on when to seek medical care through primary care, urgent care, or the emergency department,” Dr. Busuttil said. “We also provide patients with information on how to access each of these resources.”
While a prior discharge plan may have seemed ideal on paper, time and time again it’s not logistically possible for certain patients. “By having this knowledge gleaned from patient interviews, hospitalists are able to provide feedback to health systems regarding different options of outpatient care that may work for the different patient populations they serve,” Dr. Dowling said.
To understand why one particular patient population is being readmitted requires taking the time to understand that population, Dr. Dowling noted. “While many validated risk stratification tools are available, they may only serve as general guides,” she said. “To impact the population you serve, you must first understand the readmission process as it looks to them.”
Employing the HOSPITAL score
In another effort to reduce hospital readmissions, Jacques Donzé, MD, MSc, associate physician, Bern University Hospital, Switzerland, and research associate, Brigham and Women’s Hospital, Boston, and his colleagues used the HOSPITAL score to identify patients at high risk of 30-day potentially avoidable readmission.
To most efficiently reduce hospital readmissions, hospitals need to target complex and intensive discharge interventions for patients at high risk of potentially avoidable readmission who are more likely to benefit.2 “However, prior research indicates that clinical health care providers are not able to accurately identify which patients are at high risk for readmission,” Dr. Donzé said.
Dr. Donzé believes that several factors may influence the performance of a prediction model, such as the initial selection of the potential predictors, the quality of the derivation method, including readily available predictors commonly available, and including reliable factors that aren’t subject to subjective evaluation. “All of these factors can play a role in the performance and generalizability of the HOSPITAL score,” he said.
When a patient is identified as high risk to be readmitted, hospitalists can take certain actions to prevent readmission. “Interventions are more likely to be effective when they include several components,” Dr. Donzé said. “These include follow-up phone calls and/or home visits, review of the patient’s medication list, patient education, and sending a discharge summary to the patient’s primary care physician in a timely manner. For now, enough evidence for a specific effective multimodal intervention to be generalizable to the majority of patients is lacking.”
Currently, the HOSPITAL score has been validated in approximately 180,000 patients in 14 hospitals across five countries and three continents – always showing good performance and generalizability. The HOSPITAL score includes seven variables readily available before hospital discharge, is easy to use, and is the most widely validated prediction model for readmission, Dr. Donzé said.
Before being implemented into practice, a score should ideally reach the highest level of validation, that is, show its clinical impact. “We expect that the score will not only be able to accurately predict high-risk patients, but using the score will also impact patient care by reducing readmissions when coupled with an appropriate intervention,” Dr. Donzé said.
In summary, research has shown that a variety of methods can be used to reduce hospital readmissions, including studying inpatient and outpatient physicians’ perspectives regarding factors contributing to readmission; interviewing patients regarding readmissions; and identifying patients at high risk of readmission using the HOSPITAL score.
Many researchers are continuing their studies in these areas.
Karen Appold is a medical writer in Pennsylvania.
Using hospitalist reflections as a means to reduce readmissions
Readmission studies and the development of readmission scoring systems and prediction tools rely on data from a large number of patients, typically extracted from administrative databases.
To complement this data, Deanne Kashiwagi, MD, consultant, Hospital Internal Medicine, Mayo Clinic, Rochester, Minn., and her colleagues asked hospitalists to reflect upon the readmissions of patients for whom they cared to add insight into the culture of patient care transitions within the health system.
“We felt there was some value in considering these nuances of the local care environment, which may not be represented in studies drawing from large databases, as potential targets for readmission efforts,” she said.
Dr. Kashiwagi believes that including elements of local practice and culture was the strength of their work. “Groups interested in replicating this reflective process should consider including factors specific to their practices that may contribute to readmission,” she said.
Asking hospitalists to perform reviews has led to implementing changes. Physicians were prompted to schedule earlier follow-up appointments and nurse practitioners and physician assistants have worked to improve the quality of their discharge summaries. The exercise also engaged hospitalists to suggest system changes that might contribute to decreased readmissions, such as a geriatrician-run service (which was recently begun) to provide multidisciplinary acute geriatric care for hospitalized older adults.
“Although large-scale studies are clearly important, readmission review at a more granular level may have merit as well,” Dr. Kashiwagi said, noting that such reviews identify local practice factors that groups may quickly act upon to help decrease readmissions. “Hospitalists readily engaged in this reflective exercise, which yielded actionable information to decrease readmissions.”
In commenting on why a different similar study7 didn’t mimic the results of Mayo Clinic’s study, Dr. Kashiwagi said there were some differences in methodology that may explain the difference in readmission rates. “First, this group excluded patients on dialysis, which in our study was a common comorbidity of our readmitted patients,” she said. “It is also notable that the chart review tool was different. Perhaps there is less representation of local factors, unique to that hospitalist group and their practice culture, than on our review form. These investigators also discussed their readmissions at routine intervals. Additionally, their preintervention readmission rate was lower than Mayo Clinic’s group, and although the readmission rate trended downward postintervention, it did not reach statistical significance.”
References
1. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418-28.
2. Donzé JD, Williams MV, Robinson EJ, et al. International validity of the HOSPITAL Score to predict 30-day potentially avoidable hospital readmissions. JAMA Intern Med. 2016 Apr;176(4):496-502.
3. Kashiwagi DT, Burton MC, Hakim FA, et al. Reflective practice: a tool for readmission reduction. Am J Med Qual. 2016 May;31(3):265-71.
4. Herzig SJ, Schnipper JL, Doctoroff L, et al. Physician perspectives on factors contributing to readmissions and potential prevention strategies: a multicenter survey. J Gen Intern Med. 2016 Nov;31(11):1287-93. Epub 2016 Jun 9.
5. Allaudeen N, Schnipper JL, Orav EJ, et al. Inability of providers to predict unplanned readmissions. J Gen Intern Med. 2011 Jul;26(7):771-6.
6. Busuttil A, Howard-Anderson J, Dowling EP, et al. Building a comprehensive patient-centered readmission reduction program [abstract]. J Hosp Med. 2016;11(suppl 1).
7. Rana V, Thapa B, Saini SC, et al. Self-reflection as a tool to increase hospitalist participation in readmission quality improvement. Qual Manag Health Care. 2016 Oct/Dec;25(4):219-24.
Hospital value-based purchasing is largely ineffective
Over the last 5 years, I’ve periodically devoted this column to providing updates to the Hospital Value-Based Purchasing program. HVBP launched in 2013 as a 5-year mixed upside/downside incentive program with mandatory participation for all U.S. acute care hospitals (critical access, acute inpatient rehabilitation, and long-term acute care hospitals are exempt). The program initially included process and patient experience measures. It later added measures for mortality, efficiency, and patient safety.
For the 2017 version of HVBP, the measures are allocated as follows: eight for patient experience, seven for patient safety (1 of which is a roll up of 11 claims-based measures), three for process, and three for mortality. HVBP uses a budget-neutral funding approach with some winners and some losers but overall net zero spending on the program. It initially put hospitals at risk for 1% of their Medicare inpatient payments (in 2013), with a progressive increase to 2% by this year. HVBP has used a complex approach to determining incentives and penalties, rewarding either improvement or achievement, depending on the baseline performance of the hospital.
Has HVBP improved quality? Two studies looking at the early period of HVBP failed to show improvements in process or patient experience measures and demonstrated no change in mortality for heart failure, pneumonia, or heart attack.1,2 Now that the program is in its 5th and final year, thanks to a recent study by Ryan et al., we have an idea if HVBP is associated with longer-term improvements in quality.3
In the study, Ryan et al. compared hospitals participating in HVBP with critical access hospitals, which are exempt from the program. The study yielded some disappointing, if not surprising, results. Improvements in process and patient experience measures for HVBP hospitals were no greater than those for the control group. HVBP was not associated with a significant reduction in mortality for heart failure or heart attack, but was associated with a mortality reduction for pneumonia. In sum, HVBP was not associated with improvements in process or patient experience, and was not associated with lower mortality, except in pneumonia.
As a program designed to incentivize better quality, where did HVBP go wrong? I believe HVBP simply had too many measures for the cognitive bandwidth of an individual or a team looking to improve quality. The total measure count for 2017 is 21! I submit that a hospitalist working to improve quality can keep top-of-mind one or two measures, possibly three at most. While others have postulated that the amount of dollars at risk are too small, I don’t think that’s the problem. Instead, my sense is that hospitalists and other members of the hospital team have quality improvement in their DNA and, regardless of the size of the financial incentives, will work to improve it as long as they have the right tools. Chief among these are good performance data and the time to focus on a finite number of projects.
What lessons can inform better design in the future? As of January 2017, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) – representing the biggest change in reimbursement in a generation – progressively exposes doctors and other professionals to upside/downside incentives for quality, resource utilization, use of a certified electronic health record (hospitalists are exempt as they already use the hospital’s EHR), and practice improvement activities.
It would be wise to learn from the shortcomings of HVBP. Namely, if MACRA keeps on its course to incentivize physicians using a complicated formula based on four domains and many more subdomains, it will repeat the mistakes of HVBP and – while creating more administrative burden – likely improve quality very little, if at all. Instead, MACRA should delineate a simple measure set representing improvement activities that physicians and teams can incorporate into their regular work flow without more time taken away from patient care.
The reality is that complicated pay-for-performance programs divert limited available resources away from meaningful improvement activities in order to comply with onerous reporting requirements. As we gain a more nuanced understanding of how these programs work, policy makers should pay attention to the elements of “low-value” and “high-value” incentive systems and apply the “less is more” ethos of high-value care to the next generation of pay-for-performance programs.
Dr. Whitcomb is chief medical officer at Remedy Partners in Darien, Conn., and a cofounder and past president of SHM.
References
1. Ryan AM, Burgess JF, Pesko MF, Borden WB, Dimick JB. “The early effects of Medicare’s mandatory hospital pay-for-performance program” Health Serv Res. 2015;50:81-97.
2. Figueroa JF, Tsugawa Y, Zheng J, Orav EJ, Jha AK. “Association between the Value-Based Purchasing pay for performance program and patient mortality in US hospitals: observational study” BMJ. 2016;353:i2214.
3. Ryan AM, Krinsky S, Maurer KA, Dimick JB. “Changes in Hospital Quality Associated with Hospital Value-Based Purchasing” N Engl J Med. 2017;376:2358-66.
Over the last 5 years, I’ve periodically devoted this column to providing updates to the Hospital Value-Based Purchasing program. HVBP launched in 2013 as a 5-year mixed upside/downside incentive program with mandatory participation for all U.S. acute care hospitals (critical access, acute inpatient rehabilitation, and long-term acute care hospitals are exempt). The program initially included process and patient experience measures. It later added measures for mortality, efficiency, and patient safety.
For the 2017 version of HVBP, the measures are allocated as follows: eight for patient experience, seven for patient safety (1 of which is a roll up of 11 claims-based measures), three for process, and three for mortality. HVBP uses a budget-neutral funding approach with some winners and some losers but overall net zero spending on the program. It initially put hospitals at risk for 1% of their Medicare inpatient payments (in 2013), with a progressive increase to 2% by this year. HVBP has used a complex approach to determining incentives and penalties, rewarding either improvement or achievement, depending on the baseline performance of the hospital.
Has HVBP improved quality? Two studies looking at the early period of HVBP failed to show improvements in process or patient experience measures and demonstrated no change in mortality for heart failure, pneumonia, or heart attack.1,2 Now that the program is in its 5th and final year, thanks to a recent study by Ryan et al., we have an idea if HVBP is associated with longer-term improvements in quality.3
In the study, Ryan et al. compared hospitals participating in HVBP with critical access hospitals, which are exempt from the program. The study yielded some disappointing, if not surprising, results. Improvements in process and patient experience measures for HVBP hospitals were no greater than those for the control group. HVBP was not associated with a significant reduction in mortality for heart failure or heart attack, but was associated with a mortality reduction for pneumonia. In sum, HVBP was not associated with improvements in process or patient experience, and was not associated with lower mortality, except in pneumonia.
As a program designed to incentivize better quality, where did HVBP go wrong? I believe HVBP simply had too many measures for the cognitive bandwidth of an individual or a team looking to improve quality. The total measure count for 2017 is 21! I submit that a hospitalist working to improve quality can keep top-of-mind one or two measures, possibly three at most. While others have postulated that the amount of dollars at risk are too small, I don’t think that’s the problem. Instead, my sense is that hospitalists and other members of the hospital team have quality improvement in their DNA and, regardless of the size of the financial incentives, will work to improve it as long as they have the right tools. Chief among these are good performance data and the time to focus on a finite number of projects.
What lessons can inform better design in the future? As of January 2017, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) – representing the biggest change in reimbursement in a generation – progressively exposes doctors and other professionals to upside/downside incentives for quality, resource utilization, use of a certified electronic health record (hospitalists are exempt as they already use the hospital’s EHR), and practice improvement activities.
It would be wise to learn from the shortcomings of HVBP. Namely, if MACRA keeps on its course to incentivize physicians using a complicated formula based on four domains and many more subdomains, it will repeat the mistakes of HVBP and – while creating more administrative burden – likely improve quality very little, if at all. Instead, MACRA should delineate a simple measure set representing improvement activities that physicians and teams can incorporate into their regular work flow without more time taken away from patient care.
The reality is that complicated pay-for-performance programs divert limited available resources away from meaningful improvement activities in order to comply with onerous reporting requirements. As we gain a more nuanced understanding of how these programs work, policy makers should pay attention to the elements of “low-value” and “high-value” incentive systems and apply the “less is more” ethos of high-value care to the next generation of pay-for-performance programs.
Dr. Whitcomb is chief medical officer at Remedy Partners in Darien, Conn., and a cofounder and past president of SHM.
References
1. Ryan AM, Burgess JF, Pesko MF, Borden WB, Dimick JB. “The early effects of Medicare’s mandatory hospital pay-for-performance program” Health Serv Res. 2015;50:81-97.
2. Figueroa JF, Tsugawa Y, Zheng J, Orav EJ, Jha AK. “Association between the Value-Based Purchasing pay for performance program and patient mortality in US hospitals: observational study” BMJ. 2016;353:i2214.
3. Ryan AM, Krinsky S, Maurer KA, Dimick JB. “Changes in Hospital Quality Associated with Hospital Value-Based Purchasing” N Engl J Med. 2017;376:2358-66.
Over the last 5 years, I’ve periodically devoted this column to providing updates to the Hospital Value-Based Purchasing program. HVBP launched in 2013 as a 5-year mixed upside/downside incentive program with mandatory participation for all U.S. acute care hospitals (critical access, acute inpatient rehabilitation, and long-term acute care hospitals are exempt). The program initially included process and patient experience measures. It later added measures for mortality, efficiency, and patient safety.
For the 2017 version of HVBP, the measures are allocated as follows: eight for patient experience, seven for patient safety (1 of which is a roll up of 11 claims-based measures), three for process, and three for mortality. HVBP uses a budget-neutral funding approach with some winners and some losers but overall net zero spending on the program. It initially put hospitals at risk for 1% of their Medicare inpatient payments (in 2013), with a progressive increase to 2% by this year. HVBP has used a complex approach to determining incentives and penalties, rewarding either improvement or achievement, depending on the baseline performance of the hospital.
Has HVBP improved quality? Two studies looking at the early period of HVBP failed to show improvements in process or patient experience measures and demonstrated no change in mortality for heart failure, pneumonia, or heart attack.1,2 Now that the program is in its 5th and final year, thanks to a recent study by Ryan et al., we have an idea if HVBP is associated with longer-term improvements in quality.3
In the study, Ryan et al. compared hospitals participating in HVBP with critical access hospitals, which are exempt from the program. The study yielded some disappointing, if not surprising, results. Improvements in process and patient experience measures for HVBP hospitals were no greater than those for the control group. HVBP was not associated with a significant reduction in mortality for heart failure or heart attack, but was associated with a mortality reduction for pneumonia. In sum, HVBP was not associated with improvements in process or patient experience, and was not associated with lower mortality, except in pneumonia.
As a program designed to incentivize better quality, where did HVBP go wrong? I believe HVBP simply had too many measures for the cognitive bandwidth of an individual or a team looking to improve quality. The total measure count for 2017 is 21! I submit that a hospitalist working to improve quality can keep top-of-mind one or two measures, possibly three at most. While others have postulated that the amount of dollars at risk are too small, I don’t think that’s the problem. Instead, my sense is that hospitalists and other members of the hospital team have quality improvement in their DNA and, regardless of the size of the financial incentives, will work to improve it as long as they have the right tools. Chief among these are good performance data and the time to focus on a finite number of projects.
What lessons can inform better design in the future? As of January 2017, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) – representing the biggest change in reimbursement in a generation – progressively exposes doctors and other professionals to upside/downside incentives for quality, resource utilization, use of a certified electronic health record (hospitalists are exempt as they already use the hospital’s EHR), and practice improvement activities.
It would be wise to learn from the shortcomings of HVBP. Namely, if MACRA keeps on its course to incentivize physicians using a complicated formula based on four domains and many more subdomains, it will repeat the mistakes of HVBP and – while creating more administrative burden – likely improve quality very little, if at all. Instead, MACRA should delineate a simple measure set representing improvement activities that physicians and teams can incorporate into their regular work flow without more time taken away from patient care.
The reality is that complicated pay-for-performance programs divert limited available resources away from meaningful improvement activities in order to comply with onerous reporting requirements. As we gain a more nuanced understanding of how these programs work, policy makers should pay attention to the elements of “low-value” and “high-value” incentive systems and apply the “less is more” ethos of high-value care to the next generation of pay-for-performance programs.
Dr. Whitcomb is chief medical officer at Remedy Partners in Darien, Conn., and a cofounder and past president of SHM.
References
1. Ryan AM, Burgess JF, Pesko MF, Borden WB, Dimick JB. “The early effects of Medicare’s mandatory hospital pay-for-performance program” Health Serv Res. 2015;50:81-97.
2. Figueroa JF, Tsugawa Y, Zheng J, Orav EJ, Jha AK. “Association between the Value-Based Purchasing pay for performance program and patient mortality in US hospitals: observational study” BMJ. 2016;353:i2214.
3. Ryan AM, Krinsky S, Maurer KA, Dimick JB. “Changes in Hospital Quality Associated with Hospital Value-Based Purchasing” N Engl J Med. 2017;376:2358-66.
Study: Don’t separate NAS infants from moms
NASHVILLE, TENN. – When newborns withdrawing from opioids stay with their mothers after delivery instead of going to the NICU, they are far less likely to receive morphine and other drugs and leave the hospital days sooner; they also are more likely to go home with their mother, a meta-analysis showed.
The analysis likely is the first to pool results from studies of rooming-in for infants with neonatal abstinence syndrome (NAS). A strong case has been building in the literature for several years that newborns do better with rooming-in, instead of the traditional approach for NAS – NICU housing and opioid dosing based on a symptom checklist.
“We found consistent emerging evidence that rooming-in is more effective than standard care in the NICU for infants with NAS. Based on these findings, we believe rooming-in should be established as the new evidence-based standard of care for this patient population,” said investigator Kanak Verma, a medical student at Dartmouth College, Hanover, N.H.
Rooming-in was associated with a 63% reduction in the need for pharmacotherapy, a decrease in hospital length of stay by more than 10 days, and a substantial, statistically significant decrease in cost from – in one study – a mean of almost $45,000 per NAS infant stay to just over $10,000.
“We were worried that by rooming-in we would be undertreating infants with NAS, and that they would be at increased risk for readmission, but there was no statistically significant increase in readmission rates for infants rooming in with their mothers,” Ms. Verma said at the Pediatric Hospital Medical annual meeting.
Infants also were more likely to go home with their mother or a family member. “Mothers who use opioid replacements have decreased ability to bond” with their infants. Rooming-in helps create that bond, and probably made discharge with a family member more likely, said coinvestigator Cassandra Rendon, also a Dartmouth medical student.
It’s unclear what exactly accounts for the better results, but “having a baby stay with [its] mom creates an opportunity for a lot of things that we know are effective,” including skin-to-skin contact, breastfeeding, and involvement of mothers in the care and monitoring of their infants, Ms. Rendon said.
Also, “we know that in babies with NAS, a low-stimulation environment is ideal,” Ms. Verma said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. That’s a challenge in a busy NICU, but “we can create that in an isolated room with just the mother,” she added.
At least one of the studies used a new, more holistic approach to assess the need for pharmacologic management in NAS. Symptom scores still are considered, but how well the infant is eating, sleeping, and able to be consoled are considered as well. With the traditional symptom checklist, “we end up just treating the number, instead of treating the baby. What Dartmouth and other facilities are doing is looking at” how well the baby is doing overall, Ms. Rendon said.
If the baby is otherwise doing well, providers are less likely to give opioids for a little jitteriness or sweating. The decreased use of opioids leads, in turn, to shorter hospital stays.
Dartmouth is collaborating with Yale University in New Haven , Conn., and the Boston Medical Center to integrate the new treatment model into standard practice. For other centers interested in doing the same, Ms. Verma noted that nursery staff buy-in is essential. Nurses and others have to be comfortable “taking these patients out of the NICU” and treating them in a new way.
The investigators had no relevant financial disclosures.
NASHVILLE, TENN. – When newborns withdrawing from opioids stay with their mothers after delivery instead of going to the NICU, they are far less likely to receive morphine and other drugs and leave the hospital days sooner; they also are more likely to go home with their mother, a meta-analysis showed.
The analysis likely is the first to pool results from studies of rooming-in for infants with neonatal abstinence syndrome (NAS). A strong case has been building in the literature for several years that newborns do better with rooming-in, instead of the traditional approach for NAS – NICU housing and opioid dosing based on a symptom checklist.
“We found consistent emerging evidence that rooming-in is more effective than standard care in the NICU for infants with NAS. Based on these findings, we believe rooming-in should be established as the new evidence-based standard of care for this patient population,” said investigator Kanak Verma, a medical student at Dartmouth College, Hanover, N.H.
Rooming-in was associated with a 63% reduction in the need for pharmacotherapy, a decrease in hospital length of stay by more than 10 days, and a substantial, statistically significant decrease in cost from – in one study – a mean of almost $45,000 per NAS infant stay to just over $10,000.
“We were worried that by rooming-in we would be undertreating infants with NAS, and that they would be at increased risk for readmission, but there was no statistically significant increase in readmission rates for infants rooming in with their mothers,” Ms. Verma said at the Pediatric Hospital Medical annual meeting.
Infants also were more likely to go home with their mother or a family member. “Mothers who use opioid replacements have decreased ability to bond” with their infants. Rooming-in helps create that bond, and probably made discharge with a family member more likely, said coinvestigator Cassandra Rendon, also a Dartmouth medical student.
It’s unclear what exactly accounts for the better results, but “having a baby stay with [its] mom creates an opportunity for a lot of things that we know are effective,” including skin-to-skin contact, breastfeeding, and involvement of mothers in the care and monitoring of their infants, Ms. Rendon said.
Also, “we know that in babies with NAS, a low-stimulation environment is ideal,” Ms. Verma said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. That’s a challenge in a busy NICU, but “we can create that in an isolated room with just the mother,” she added.
At least one of the studies used a new, more holistic approach to assess the need for pharmacologic management in NAS. Symptom scores still are considered, but how well the infant is eating, sleeping, and able to be consoled are considered as well. With the traditional symptom checklist, “we end up just treating the number, instead of treating the baby. What Dartmouth and other facilities are doing is looking at” how well the baby is doing overall, Ms. Rendon said.
If the baby is otherwise doing well, providers are less likely to give opioids for a little jitteriness or sweating. The decreased use of opioids leads, in turn, to shorter hospital stays.
Dartmouth is collaborating with Yale University in New Haven , Conn., and the Boston Medical Center to integrate the new treatment model into standard practice. For other centers interested in doing the same, Ms. Verma noted that nursery staff buy-in is essential. Nurses and others have to be comfortable “taking these patients out of the NICU” and treating them in a new way.
The investigators had no relevant financial disclosures.
NASHVILLE, TENN. – When newborns withdrawing from opioids stay with their mothers after delivery instead of going to the NICU, they are far less likely to receive morphine and other drugs and leave the hospital days sooner; they also are more likely to go home with their mother, a meta-analysis showed.
The analysis likely is the first to pool results from studies of rooming-in for infants with neonatal abstinence syndrome (NAS). A strong case has been building in the literature for several years that newborns do better with rooming-in, instead of the traditional approach for NAS – NICU housing and opioid dosing based on a symptom checklist.
“We found consistent emerging evidence that rooming-in is more effective than standard care in the NICU for infants with NAS. Based on these findings, we believe rooming-in should be established as the new evidence-based standard of care for this patient population,” said investigator Kanak Verma, a medical student at Dartmouth College, Hanover, N.H.
Rooming-in was associated with a 63% reduction in the need for pharmacotherapy, a decrease in hospital length of stay by more than 10 days, and a substantial, statistically significant decrease in cost from – in one study – a mean of almost $45,000 per NAS infant stay to just over $10,000.
“We were worried that by rooming-in we would be undertreating infants with NAS, and that they would be at increased risk for readmission, but there was no statistically significant increase in readmission rates for infants rooming in with their mothers,” Ms. Verma said at the Pediatric Hospital Medical annual meeting.
Infants also were more likely to go home with their mother or a family member. “Mothers who use opioid replacements have decreased ability to bond” with their infants. Rooming-in helps create that bond, and probably made discharge with a family member more likely, said coinvestigator Cassandra Rendon, also a Dartmouth medical student.
It’s unclear what exactly accounts for the better results, but “having a baby stay with [its] mom creates an opportunity for a lot of things that we know are effective,” including skin-to-skin contact, breastfeeding, and involvement of mothers in the care and monitoring of their infants, Ms. Rendon said.
Also, “we know that in babies with NAS, a low-stimulation environment is ideal,” Ms. Verma said at the meeting, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association. That’s a challenge in a busy NICU, but “we can create that in an isolated room with just the mother,” she added.
At least one of the studies used a new, more holistic approach to assess the need for pharmacologic management in NAS. Symptom scores still are considered, but how well the infant is eating, sleeping, and able to be consoled are considered as well. With the traditional symptom checklist, “we end up just treating the number, instead of treating the baby. What Dartmouth and other facilities are doing is looking at” how well the baby is doing overall, Ms. Rendon said.
If the baby is otherwise doing well, providers are less likely to give opioids for a little jitteriness or sweating. The decreased use of opioids leads, in turn, to shorter hospital stays.
Dartmouth is collaborating with Yale University in New Haven , Conn., and the Boston Medical Center to integrate the new treatment model into standard practice. For other centers interested in doing the same, Ms. Verma noted that nursery staff buy-in is essential. Nurses and others have to be comfortable “taking these patients out of the NICU” and treating them in a new way.
The investigators had no relevant financial disclosures.
AT PHM 2017
Key clinical point:
Major finding: Rooming-in was associated with a 63% reduction in the need for pharmacotherapy, a decrease in hospital length of stay by more than 10 days, and a substantial, statistically significant decrease in cost from, in one study, a mean of almost $45,000 per NAS infant stay to just over $10,000.
Data source: A meta-analysis of six studies.
Disclosures: The investigators had no relevant financial disclosures.
Ivabradine cut mortality in HFrEF patients not on beta-blocker
BARCELONA – The time is right for a placebo-controlled, randomized trial of ivabradine in patients with heart failure with reduced ejection fraction who are unwilling or unable to take a beta-blocker as recommended in the guidelines, John G.F. Cleland, MD, asserted at the annual congress of the European Society of Cardiology.
He cited as the rationale for such a study a new post-hoc analysis of data from the SHIFT trial showing that ivabradine (Corlanor) significantly reduced both cardiovascular and all-cause mortality, as well as hospitalizations for heart failure, in the subset of study participants who weren’t on beta-blocker therapy.
“I think there would be ethical equipoise,” he added. “If patients are unwilling or unable to take a beta-blocker, or their cardiologist feels it’s not in their best interest, then I certainly think a placebo-controlled trial would not only be appropriate, but there’s also an onus on the cardiology community to do such a trial.”
Ivabradine slows heart rate by a unique mechanism that doesn’t involve blockade of adrenergic receptors. In the SHIFT trial (Lancet. 2010 Sep 11;376[9744]:875-85), more than 6,500 patients with heart failure with reduced ejection fraction (HFrEF) in sinus rhythm and with a heart rate greater than 70 bpm were randomized to ivabradine or placebo on top of guideline-directed medical therapy for heart failure. During a median 23 months of follow-up, heart failure hospitalizations were significantly reduced by 26% in the ivabradine group, although cardiovascular deaths were not significantly affected.
As a result of the SHIFT findings, the drug was approved with an indication for use only in combination with a beta-blocker in patients with HFrEF whose on-treatment heart rate exceeds 70 bpm. Ivabradine is not currently recommended as an alternative to beta-blocker therapy. However, in real-world clinical practice a large number of heart failure patients are not managed with a beta-blocker, the cardiologist noted.
His post-hoc analysis focused on the 685 SHIFT participants who were not on a beta-blocker at randomization. During follow-up, there were 93 deaths among patients who were on placebo and only 71 in those randomized to ivabradine, for a statistically significant 30% reduction in all-cause mortality. Cardiovascular mortality was reduced to a similar extent. These hazard ratios remained similar after adjusting for differences in heart rate and other clinical characteristics.
“Beta-blockers are a highly effective therapy for heart failure with reduced ejection fraction, but the mechanism of benefit remains uncertain. It might simply be due to heart rate reduction. And I would point out that we have no evidence of a dose response for beta-blockers: It may well be that you get most of the effect of a beta-blocker with the lowest dose. Titrating to the full dose of a beta-blocker might only be helpful in that it lowers your heart rate. I would argue that 6.25 mg/day of carvedilol plus ivabradine might be as good as 50 mg twice daily of carvedilol but with much higher patient acceptability. We don’t know,” said Dr. Cleland.
“This is an interesting, hypothesis-generating analysis, and we need confirmation now that ivabradine reduces mortality in heart failure patients who are unwilling or unable to take a beta-blocker,” he concluded.
The SHIFT trial was sponsored by Servier. Dr. Cleland reported serving as a consultant to and receiving research funding from that company and others.
BARCELONA – The time is right for a placebo-controlled, randomized trial of ivabradine in patients with heart failure with reduced ejection fraction who are unwilling or unable to take a beta-blocker as recommended in the guidelines, John G.F. Cleland, MD, asserted at the annual congress of the European Society of Cardiology.
He cited as the rationale for such a study a new post-hoc analysis of data from the SHIFT trial showing that ivabradine (Corlanor) significantly reduced both cardiovascular and all-cause mortality, as well as hospitalizations for heart failure, in the subset of study participants who weren’t on beta-blocker therapy.
“I think there would be ethical equipoise,” he added. “If patients are unwilling or unable to take a beta-blocker, or their cardiologist feels it’s not in their best interest, then I certainly think a placebo-controlled trial would not only be appropriate, but there’s also an onus on the cardiology community to do such a trial.”
Ivabradine slows heart rate by a unique mechanism that doesn’t involve blockade of adrenergic receptors. In the SHIFT trial (Lancet. 2010 Sep 11;376[9744]:875-85), more than 6,500 patients with heart failure with reduced ejection fraction (HFrEF) in sinus rhythm and with a heart rate greater than 70 bpm were randomized to ivabradine or placebo on top of guideline-directed medical therapy for heart failure. During a median 23 months of follow-up, heart failure hospitalizations were significantly reduced by 26% in the ivabradine group, although cardiovascular deaths were not significantly affected.
As a result of the SHIFT findings, the drug was approved with an indication for use only in combination with a beta-blocker in patients with HFrEF whose on-treatment heart rate exceeds 70 bpm. Ivabradine is not currently recommended as an alternative to beta-blocker therapy. However, in real-world clinical practice a large number of heart failure patients are not managed with a beta-blocker, the cardiologist noted.
His post-hoc analysis focused on the 685 SHIFT participants who were not on a beta-blocker at randomization. During follow-up, there were 93 deaths among patients who were on placebo and only 71 in those randomized to ivabradine, for a statistically significant 30% reduction in all-cause mortality. Cardiovascular mortality was reduced to a similar extent. These hazard ratios remained similar after adjusting for differences in heart rate and other clinical characteristics.
“Beta-blockers are a highly effective therapy for heart failure with reduced ejection fraction, but the mechanism of benefit remains uncertain. It might simply be due to heart rate reduction. And I would point out that we have no evidence of a dose response for beta-blockers: It may well be that you get most of the effect of a beta-blocker with the lowest dose. Titrating to the full dose of a beta-blocker might only be helpful in that it lowers your heart rate. I would argue that 6.25 mg/day of carvedilol plus ivabradine might be as good as 50 mg twice daily of carvedilol but with much higher patient acceptability. We don’t know,” said Dr. Cleland.
“This is an interesting, hypothesis-generating analysis, and we need confirmation now that ivabradine reduces mortality in heart failure patients who are unwilling or unable to take a beta-blocker,” he concluded.
The SHIFT trial was sponsored by Servier. Dr. Cleland reported serving as a consultant to and receiving research funding from that company and others.
BARCELONA – The time is right for a placebo-controlled, randomized trial of ivabradine in patients with heart failure with reduced ejection fraction who are unwilling or unable to take a beta-blocker as recommended in the guidelines, John G.F. Cleland, MD, asserted at the annual congress of the European Society of Cardiology.
He cited as the rationale for such a study a new post-hoc analysis of data from the SHIFT trial showing that ivabradine (Corlanor) significantly reduced both cardiovascular and all-cause mortality, as well as hospitalizations for heart failure, in the subset of study participants who weren’t on beta-blocker therapy.
“I think there would be ethical equipoise,” he added. “If patients are unwilling or unable to take a beta-blocker, or their cardiologist feels it’s not in their best interest, then I certainly think a placebo-controlled trial would not only be appropriate, but there’s also an onus on the cardiology community to do such a trial.”
Ivabradine slows heart rate by a unique mechanism that doesn’t involve blockade of adrenergic receptors. In the SHIFT trial (Lancet. 2010 Sep 11;376[9744]:875-85), more than 6,500 patients with heart failure with reduced ejection fraction (HFrEF) in sinus rhythm and with a heart rate greater than 70 bpm were randomized to ivabradine or placebo on top of guideline-directed medical therapy for heart failure. During a median 23 months of follow-up, heart failure hospitalizations were significantly reduced by 26% in the ivabradine group, although cardiovascular deaths were not significantly affected.
As a result of the SHIFT findings, the drug was approved with an indication for use only in combination with a beta-blocker in patients with HFrEF whose on-treatment heart rate exceeds 70 bpm. Ivabradine is not currently recommended as an alternative to beta-blocker therapy. However, in real-world clinical practice a large number of heart failure patients are not managed with a beta-blocker, the cardiologist noted.
His post-hoc analysis focused on the 685 SHIFT participants who were not on a beta-blocker at randomization. During follow-up, there were 93 deaths among patients who were on placebo and only 71 in those randomized to ivabradine, for a statistically significant 30% reduction in all-cause mortality. Cardiovascular mortality was reduced to a similar extent. These hazard ratios remained similar after adjusting for differences in heart rate and other clinical characteristics.
“Beta-blockers are a highly effective therapy for heart failure with reduced ejection fraction, but the mechanism of benefit remains uncertain. It might simply be due to heart rate reduction. And I would point out that we have no evidence of a dose response for beta-blockers: It may well be that you get most of the effect of a beta-blocker with the lowest dose. Titrating to the full dose of a beta-blocker might only be helpful in that it lowers your heart rate. I would argue that 6.25 mg/day of carvedilol plus ivabradine might be as good as 50 mg twice daily of carvedilol but with much higher patient acceptability. We don’t know,” said Dr. Cleland.
“This is an interesting, hypothesis-generating analysis, and we need confirmation now that ivabradine reduces mortality in heart failure patients who are unwilling or unable to take a beta-blocker,” he concluded.
The SHIFT trial was sponsored by Servier. Dr. Cleland reported serving as a consultant to and receiving research funding from that company and others.
AT THE ESC CONGRESS 2017
Key clinical point:
Major finding: All-cause mortality was reduced by 30%, compared with placebo, in ivabradine-treated patients with heart failure with reduced ejection fraction who were not on a beta-blocker.
Data source: A post-hoc analysis of the 685 patients in a much larger randomized, placebo-controlled clinical trial of ivabradine in patients with heart failure with reduced ejection fraction.
Disclosures: The SHIFT trial was funded by Servier. The presenter reported serving as a consultant to and recipient of research grants from that and other companies.
Short Takes
Hospitalized-patient one-year mortality risk (HOMR) score an excellent prognostic tool
The HOMR score, derived from administrative data, accurately predicts mortality. This study derived the score from medical records which providers can access and found it still accurately determines 1-year mortality.
Citation: Casey G, van Walraven C. Prognosticating with the hospitalized-patient one-year mortality risk score using information abstracted from the medical record. J Hosp Med. 2017 April; 12(4):224-30.
New drug for C. difficile recurrence
Bezlotoxumab is now approved to reduce recurrence of Clostridium difficile. This is an injectable human monoclonal antibody to C. difficile toxin and must be used in conjunction with antibiotics.
Citation: U.S. Food and Drug Administration. Drug Label. Available online at https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/761046s000lbl.pdf. Accessed 7 May 2017.
Hospitalized-patient one-year mortality risk (HOMR) score an excellent prognostic tool
The HOMR score, derived from administrative data, accurately predicts mortality. This study derived the score from medical records which providers can access and found it still accurately determines 1-year mortality.
Citation: Casey G, van Walraven C. Prognosticating with the hospitalized-patient one-year mortality risk score using information abstracted from the medical record. J Hosp Med. 2017 April; 12(4):224-30.
New drug for C. difficile recurrence
Bezlotoxumab is now approved to reduce recurrence of Clostridium difficile. This is an injectable human monoclonal antibody to C. difficile toxin and must be used in conjunction with antibiotics.
Citation: U.S. Food and Drug Administration. Drug Label. Available online at https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/761046s000lbl.pdf. Accessed 7 May 2017.
Hospitalized-patient one-year mortality risk (HOMR) score an excellent prognostic tool
The HOMR score, derived from administrative data, accurately predicts mortality. This study derived the score from medical records which providers can access and found it still accurately determines 1-year mortality.
Citation: Casey G, van Walraven C. Prognosticating with the hospitalized-patient one-year mortality risk score using information abstracted from the medical record. J Hosp Med. 2017 April; 12(4):224-30.
New drug for C. difficile recurrence
Bezlotoxumab is now approved to reduce recurrence of Clostridium difficile. This is an injectable human monoclonal antibody to C. difficile toxin and must be used in conjunction with antibiotics.
Citation: U.S. Food and Drug Administration. Drug Label. Available online at https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/761046s000lbl.pdf. Accessed 7 May 2017.
Heart failure guidelines updated
Clinical Question: What new evidence is available to guide heart failure (HF) management?
Background: New data has become available since the 2013 HF guidelines.
Study Design: A focused update.
Setting: Ongoing review of HF literature.
Synopsis: Beta-natriuretic peptide (BNP) is recommended to screen at risk patients (IIaB), on admission (IA), and prior to discharge (IIaB). The combination of ARB and neprilysin inhibitor (ARB-NI) is recommended in symptomatic patients with HF with reduced ejection fraction (HFrEF) who are tolerant of ACE inhibition (IB). For these patients, transitioning from ACE-inhibitor to the ARB-NI combination, valsartan-sacubitril significantly reduced hospitalization and mortality. Optimal dose and titration strategies remain unclear. ARB-NIs should not be used in patients with a history of angioedema (IIIC) or within 36 hours of receiving ACE-inhibitors (IIIB). Ivabradine, a selective inhibitor of the If current in the sinoatrial node, is recommended to reduce hospitalizations for patients with HFrEF with stable symptoms with resting sinus heart rate greater than or equal to 70 despite maximally-tolerated beta-blockade (IIaB). Intravenous iron replacement is recommended to improve function and quality of life for patients with symptomatic HF and iron deficiency (IIbB).
Bottom Line: Updates support use of BNP, ARB-NIs, ivabradine, and IV iron for HFrEF.
Citation: Yancy CW, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: A report of the American college of cardiology/American heart association task force on clinical practice guidelines and the heart failure society of America. Published online, 2017 Apr 28. Circulation. doi: 10.1161/CIR.0000000000000509.
Dr. Sweigart is an assistant professor in the University of Kentucky division of hospital medicine and Lexington VA Medical Center.
Clinical Question: What new evidence is available to guide heart failure (HF) management?
Background: New data has become available since the 2013 HF guidelines.
Study Design: A focused update.
Setting: Ongoing review of HF literature.
Synopsis: Beta-natriuretic peptide (BNP) is recommended to screen at risk patients (IIaB), on admission (IA), and prior to discharge (IIaB). The combination of ARB and neprilysin inhibitor (ARB-NI) is recommended in symptomatic patients with HF with reduced ejection fraction (HFrEF) who are tolerant of ACE inhibition (IB). For these patients, transitioning from ACE-inhibitor to the ARB-NI combination, valsartan-sacubitril significantly reduced hospitalization and mortality. Optimal dose and titration strategies remain unclear. ARB-NIs should not be used in patients with a history of angioedema (IIIC) or within 36 hours of receiving ACE-inhibitors (IIIB). Ivabradine, a selective inhibitor of the If current in the sinoatrial node, is recommended to reduce hospitalizations for patients with HFrEF with stable symptoms with resting sinus heart rate greater than or equal to 70 despite maximally-tolerated beta-blockade (IIaB). Intravenous iron replacement is recommended to improve function and quality of life for patients with symptomatic HF and iron deficiency (IIbB).
Bottom Line: Updates support use of BNP, ARB-NIs, ivabradine, and IV iron for HFrEF.
Citation: Yancy CW, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: A report of the American college of cardiology/American heart association task force on clinical practice guidelines and the heart failure society of America. Published online, 2017 Apr 28. Circulation. doi: 10.1161/CIR.0000000000000509.
Dr. Sweigart is an assistant professor in the University of Kentucky division of hospital medicine and Lexington VA Medical Center.
Clinical Question: What new evidence is available to guide heart failure (HF) management?
Background: New data has become available since the 2013 HF guidelines.
Study Design: A focused update.
Setting: Ongoing review of HF literature.
Synopsis: Beta-natriuretic peptide (BNP) is recommended to screen at risk patients (IIaB), on admission (IA), and prior to discharge (IIaB). The combination of ARB and neprilysin inhibitor (ARB-NI) is recommended in symptomatic patients with HF with reduced ejection fraction (HFrEF) who are tolerant of ACE inhibition (IB). For these patients, transitioning from ACE-inhibitor to the ARB-NI combination, valsartan-sacubitril significantly reduced hospitalization and mortality. Optimal dose and titration strategies remain unclear. ARB-NIs should not be used in patients with a history of angioedema (IIIC) or within 36 hours of receiving ACE-inhibitors (IIIB). Ivabradine, a selective inhibitor of the If current in the sinoatrial node, is recommended to reduce hospitalizations for patients with HFrEF with stable symptoms with resting sinus heart rate greater than or equal to 70 despite maximally-tolerated beta-blockade (IIaB). Intravenous iron replacement is recommended to improve function and quality of life for patients with symptomatic HF and iron deficiency (IIbB).
Bottom Line: Updates support use of BNP, ARB-NIs, ivabradine, and IV iron for HFrEF.
Citation: Yancy CW, et al. 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: A report of the American college of cardiology/American heart association task force on clinical practice guidelines and the heart failure society of America. Published online, 2017 Apr 28. Circulation. doi: 10.1161/CIR.0000000000000509.
Dr. Sweigart is an assistant professor in the University of Kentucky division of hospital medicine and Lexington VA Medical Center.
Triple therapy reduces exacerbations in patients with symptomatic COPD
Clinical Question: Does triple therapy (long-acting beta2-agonist, long-acting muscarinic antagonist, and inhaled corticosteroid) reduce exacerbations in patients with symptomatic chronic obstructive pulmonary disease (COPD)?
Background: Guidelines from GOLD and NICE recommend considering a step-up to triple therapy for patients with refractory COPD symptoms or exacerbations. However, it is unknown if this reduces the long term risk of exacerbations.
Study Design: A randomized controlled trial.
Synopsis: This study enrolled 2,691 patients with COPD, severe airflow restriction (FEV1 less than 50%), significant symptoms (CAT score greater than or equal to 10), and at least one exacerbation in the past year. Participants were randomized to a novel three-agent inhaler (containing an extrafine formulation of beclomethasone, formoterol, and glycopyrronium), an “open triple” regimen including beclomethasone/formoterol plus tiotropium, or to tiotropium alone.
During 52 weeks of treatment, the triple therapy regimens significantly reduced moderate to severe COPD exacerbations, compared with tiotropium alone, with annualized exacerbation rates of 0.46 (95% confidence interval, 0.41-0.51), 0.45 (0.39-0.52), and 0.57 (0.52-0.63), respectively. Rates of adverse events were similar between all three groups.
Bottom Line: Triple therapy was superior to tiotropium alone for reducing exacerbations in patients with symptomatic COPD. The two triple therapy regimens studied did not significantly differ in efficacy.
Citation: Vestbo J, Papi A, Corradi M, et al. Single inhaler extrafine triple therapy versus long-acting muscarinic antagonist therapy for chronic obstructive pulmonary disease (TRINITY): A double-blind, parallel group, randomized controlled trial. Lancet. 2017;389(10082):1919-29.
Dr. Troy is assistant professor in the University of Kentucky division of hospital medicine.
Clinical Question: Does triple therapy (long-acting beta2-agonist, long-acting muscarinic antagonist, and inhaled corticosteroid) reduce exacerbations in patients with symptomatic chronic obstructive pulmonary disease (COPD)?
Background: Guidelines from GOLD and NICE recommend considering a step-up to triple therapy for patients with refractory COPD symptoms or exacerbations. However, it is unknown if this reduces the long term risk of exacerbations.
Study Design: A randomized controlled trial.
Synopsis: This study enrolled 2,691 patients with COPD, severe airflow restriction (FEV1 less than 50%), significant symptoms (CAT score greater than or equal to 10), and at least one exacerbation in the past year. Participants were randomized to a novel three-agent inhaler (containing an extrafine formulation of beclomethasone, formoterol, and glycopyrronium), an “open triple” regimen including beclomethasone/formoterol plus tiotropium, or to tiotropium alone.
During 52 weeks of treatment, the triple therapy regimens significantly reduced moderate to severe COPD exacerbations, compared with tiotropium alone, with annualized exacerbation rates of 0.46 (95% confidence interval, 0.41-0.51), 0.45 (0.39-0.52), and 0.57 (0.52-0.63), respectively. Rates of adverse events were similar between all three groups.
Bottom Line: Triple therapy was superior to tiotropium alone for reducing exacerbations in patients with symptomatic COPD. The two triple therapy regimens studied did not significantly differ in efficacy.
Citation: Vestbo J, Papi A, Corradi M, et al. Single inhaler extrafine triple therapy versus long-acting muscarinic antagonist therapy for chronic obstructive pulmonary disease (TRINITY): A double-blind, parallel group, randomized controlled trial. Lancet. 2017;389(10082):1919-29.
Dr. Troy is assistant professor in the University of Kentucky division of hospital medicine.
Clinical Question: Does triple therapy (long-acting beta2-agonist, long-acting muscarinic antagonist, and inhaled corticosteroid) reduce exacerbations in patients with symptomatic chronic obstructive pulmonary disease (COPD)?
Background: Guidelines from GOLD and NICE recommend considering a step-up to triple therapy for patients with refractory COPD symptoms or exacerbations. However, it is unknown if this reduces the long term risk of exacerbations.
Study Design: A randomized controlled trial.
Synopsis: This study enrolled 2,691 patients with COPD, severe airflow restriction (FEV1 less than 50%), significant symptoms (CAT score greater than or equal to 10), and at least one exacerbation in the past year. Participants were randomized to a novel three-agent inhaler (containing an extrafine formulation of beclomethasone, formoterol, and glycopyrronium), an “open triple” regimen including beclomethasone/formoterol plus tiotropium, or to tiotropium alone.
During 52 weeks of treatment, the triple therapy regimens significantly reduced moderate to severe COPD exacerbations, compared with tiotropium alone, with annualized exacerbation rates of 0.46 (95% confidence interval, 0.41-0.51), 0.45 (0.39-0.52), and 0.57 (0.52-0.63), respectively. Rates of adverse events were similar between all three groups.
Bottom Line: Triple therapy was superior to tiotropium alone for reducing exacerbations in patients with symptomatic COPD. The two triple therapy regimens studied did not significantly differ in efficacy.
Citation: Vestbo J, Papi A, Corradi M, et al. Single inhaler extrafine triple therapy versus long-acting muscarinic antagonist therapy for chronic obstructive pulmonary disease (TRINITY): A double-blind, parallel group, randomized controlled trial. Lancet. 2017;389(10082):1919-29.
Dr. Troy is assistant professor in the University of Kentucky division of hospital medicine.