The Hospitalist

BARCELONA – Combined treatment with a very low dosage of the anticoagulant rivaroxaban plus low-dose aspirin produced significant cuts in major adverse coronary, cerebral, and peripheral artery disease events with just a modest rise in major bleeding events in patients with stable disease in the COMPASS pivotal, randomized trial with more than 27,000 patients.

The benefits from the rivaroxaban plus aspirin regimen included a statistically significant 24% relative risk reduction in the study’s primary, combined endpoint, and a significant 18% relative risk reduction in all-cause death compared with a standard regimen of aspirin only, John W. Eikelboom, MD, said at the annual congress of the European Society of Cardiology. In addition, analysis of the net clinical benefit from treatment that took into account both the major adverse cardiovascular events prevented and major bleeding events induced, showed that the rivaroxaban-plus-aspirin regimen cut these by a statistically significant 20%, compared with aspirin alone.

Other notable benefits documented by the findings included a statistically significant 42% relative risk reduction for stroke and a statistically significant 46% relative risk reduction in the incidence of major adverse limb events among the roughly one-quarter of enrolled patients who entered the study with evidence of peripheral artery disease.

These risk reductions are similar in magnitude to the secondary-prevention benefits produced by controlling hypertension or dyslipidemia, noted Dr. Eikelboom, a researcher at McMaster University in Hamilton, Ont. “In the future, rivaroxaban will take its place among the other foundational treatments for long-term, secondary prevention,” he predicted in a video interview.

The COMPASS trial produced “unambiguous results that should change guidelines and the management of stable coronary artery disease,” commented Eugene Braunwald, MD, designated discussant for Dr. Eikelboom’s report. The results are “an important step for thrombocardiology,” said Dr. Braunwald, professor of medicine at Harvard Medical School in Boston.

Concurrently with Dr. Eikelboom’s report the results appeared in an article published online (N Engl J Med. 2017 Aug 27. doi: 10.1056/NEJMoa1709118). This publication also include an editorial by Dr. Braunwald (N Engl J Med. 2017 Aug 27. doi: 10.1056/NEJMe1710241).

Mitchel L. Zoler/Frontline Medical News

Mitchel L. Zoler/Frontline Medical News

[email protected]

On Twitter @mitchelzoler

BARCELONA – Combined treatment with a very low dosage of the anticoagulant rivaroxaban plus low-dose aspirin produced significant cuts in major adverse coronary, cerebral, and peripheral artery disease events with just a modest rise in major bleeding events in patients with stable disease in the COMPASS pivotal, randomized trial with more than 27,000 patients.

The benefits from the rivaroxaban plus aspirin regimen included a statistically significant 24% relative risk reduction in the study’s primary, combined endpoint, and a significant 18% relative risk reduction in all-cause death compared with a standard regimen of aspirin only, John W. Eikelboom, MD, said at the annual congress of the European Society of Cardiology. In addition, analysis of the net clinical benefit from treatment that took into account both the major adverse cardiovascular events prevented and major bleeding events induced, showed that the rivaroxaban-plus-aspirin regimen cut these by a statistically significant 20%, compared with aspirin alone.

Other notable benefits documented by the findings included a statistically significant 42% relative risk reduction for stroke and a statistically significant 46% relative risk reduction in the incidence of major adverse limb events among the roughly one-quarter of enrolled patients who entered the study with evidence of peripheral artery disease.

These risk reductions are similar in magnitude to the secondary-prevention benefits produced by controlling hypertension or dyslipidemia, noted Dr. Eikelboom, a researcher at McMaster University in Hamilton, Ont. “In the future, rivaroxaban will take its place among the other foundational treatments for long-term, secondary prevention,” he predicted in a video interview.

The COMPASS trial produced “unambiguous results that should change guidelines and the management of stable coronary artery disease,” commented Eugene Braunwald, MD, designated discussant for Dr. Eikelboom’s report. The results are “an important step for thrombocardiology,” said Dr. Braunwald, professor of medicine at Harvard Medical School in Boston.

Concurrently with Dr. Eikelboom’s report the results appeared in an article published online (N Engl J Med. 2017 Aug 27. doi: 10.1056/NEJMoa1709118). This publication also include an editorial by Dr. Braunwald (N Engl J Med. 2017 Aug 27. doi: 10.1056/NEJMe1710241).

Mitchel L. Zoler/Frontline Medical News

Mitchel L. Zoler/Frontline Medical News

[email protected]

On Twitter @mitchelzoler

BARCELONA – Combined treatment with a very low dosage of the anticoagulant rivaroxaban plus low-dose aspirin produced significant cuts in major adverse coronary, cerebral, and peripheral artery disease events with just a modest rise in major bleeding events in patients with stable disease in the COMPASS pivotal, randomized trial with more than 27,000 patients.

The benefits from the rivaroxaban plus aspirin regimen included a statistically significant 24% relative risk reduction in the study’s primary, combined endpoint, and a significant 18% relative risk reduction in all-cause death compared with a standard regimen of aspirin only, John W. Eikelboom, MD, said at the annual congress of the European Society of Cardiology. In addition, analysis of the net clinical benefit from treatment that took into account both the major adverse cardiovascular events prevented and major bleeding events induced, showed that the rivaroxaban-plus-aspirin regimen cut these by a statistically significant 20%, compared with aspirin alone.

Other notable benefits documented by the findings included a statistically significant 42% relative risk reduction for stroke and a statistically significant 46% relative risk reduction in the incidence of major adverse limb events among the roughly one-quarter of enrolled patients who entered the study with evidence of peripheral artery disease.

These risk reductions are similar in magnitude to the secondary-prevention benefits produced by controlling hypertension or dyslipidemia, noted Dr. Eikelboom, a researcher at McMaster University in Hamilton, Ont. “In the future, rivaroxaban will take its place among the other foundational treatments for long-term, secondary prevention,” he predicted in a video interview.

The COMPASS trial produced “unambiguous results that should change guidelines and the management of stable coronary artery disease,” commented Eugene Braunwald, MD, designated discussant for Dr. Eikelboom’s report. The results are “an important step for thrombocardiology,” said Dr. Braunwald, professor of medicine at Harvard Medical School in Boston.

Concurrently with Dr. Eikelboom’s report the results appeared in an article published online (N Engl J Med. 2017 Aug 27. doi: 10.1056/NEJMoa1709118). This publication also include an editorial by Dr. Braunwald (N Engl J Med. 2017 Aug 27. doi: 10.1056/NEJMe1710241).

Mitchel L. Zoler/Frontline Medical News

Mitchel L. Zoler/Frontline Medical News

[email protected]

On Twitter @mitchelzoler

Quality improvement became a foundational theme for SHM early in the growth of hospitalists. It’s not a coincidence that many of our leaders, such as Bob Wachter, Win Whitcomb, Greg Maynard, and Mark Williams are QI leaders as well. As hospitalists, we were and are best positioned to impact quality in the hospital.

Eric Howell, MD, of Johns Hopkins Bayview Medical Center in Baltimore serves as the senior physician advisor for SHM’s Center for Quality Improvement, while Jenna Goldstein runs the day-to-day aspects at SHM headquarters. A few months ago, Dr. Howell and I discussed how he started in QI, the role of SHM’s Center, and how hospitalists can receive effective QI training. The following Q&A is edited for conciseness and clarity.

You’ve been a leader in QI for many years; how did you get started in QI?

I trained as an electrical engineer before I went to medical school, which helped me when I went to residency.

When I was a chief at Hopkins Bayview in 1999, there were a number of systems-related issues, including throughput from the emergency department. I became involved with QI because I looked at these systems, thinking they could be better if I used the lens of an engineer. The hospital was very interested in reducing costs, and the physicians, including myself, were interested in making things safer. I was successful because I didn’t just focus on QI but on both sides of the value equation. In the early 2000s, I started to do more and more re-engineering and system improvement projects, and I found them very rewarding. As I showed some success, I was asked to do more.

What you are describing is hands-on training, learning by doing. It seems a lot of your QI training was hands on, as opposed to structured coursework. Was there formal training or is getting your hands dirty in a project the best way to start learning QI?

There is no replacement for actually doing it.

My training was in leadership, which is an integral part of QI. It’s pretty hard to get people to change for quality if you can’t lead them through that change. Initially, I did a lot of work to improve my leadership potential. As faculty, we taught teaching skills, which is a part of leadership. I spent time teaching residents best practices. That’s why I became involved early on with SHM’s Leadership Academy from its start in 2005. I also read a lot of books and still read often to improve my weaknesses. I have my own physicians go through Lean Six Sigma training and get their green belt or black belt.

That said, there is no substitute for doing it and, as they say, “bruising your knuckles” in QI.

Read the full post at hospitalleader.org.

Also on The Hospital Leader…

• From SXSW to SHM: Our Tour to Promote Value Conversations Between Doctors & Patients by Chris Moriates, MD
• It’s Time for a Buzz Cut by Tracy Cardin, ACNP-NC, SFHM
• The Essentials of QI Leadership: A Conversation with Dr. Eric Howell, Part 2 by Jordan Messler, MD, SFHM

Quality improvement became a foundational theme for SHM early in the growth of hospitalists. It’s not a coincidence that many of our leaders, such as Bob Wachter, Win Whitcomb, Greg Maynard, and Mark Williams are QI leaders as well. As hospitalists, we were and are best positioned to impact quality in the hospital.

Eric Howell, MD, of Johns Hopkins Bayview Medical Center in Baltimore serves as the senior physician advisor for SHM’s Center for Quality Improvement, while Jenna Goldstein runs the day-to-day aspects at SHM headquarters. A few months ago, Dr. Howell and I discussed how he started in QI, the role of SHM’s Center, and how hospitalists can receive effective QI training. The following Q&A is edited for conciseness and clarity.

You’ve been a leader in QI for many years; how did you get started in QI?

I trained as an electrical engineer before I went to medical school, which helped me when I went to residency.

When I was a chief at Hopkins Bayview in 1999, there were a number of systems-related issues, including throughput from the emergency department. I became involved with QI because I looked at these systems, thinking they could be better if I used the lens of an engineer. The hospital was very interested in reducing costs, and the physicians, including myself, were interested in making things safer. I was successful because I didn’t just focus on QI but on both sides of the value equation. In the early 2000s, I started to do more and more re-engineering and system improvement projects, and I found them very rewarding. As I showed some success, I was asked to do more.

What you are describing is hands-on training, learning by doing. It seems a lot of your QI training was hands on, as opposed to structured coursework. Was there formal training or is getting your hands dirty in a project the best way to start learning QI?

There is no replacement for actually doing it.

My training was in leadership, which is an integral part of QI. It’s pretty hard to get people to change for quality if you can’t lead them through that change. Initially, I did a lot of work to improve my leadership potential. As faculty, we taught teaching skills, which is a part of leadership. I spent time teaching residents best practices. That’s why I became involved early on with SHM’s Leadership Academy from its start in 2005. I also read a lot of books and still read often to improve my weaknesses. I have my own physicians go through Lean Six Sigma training and get their green belt or black belt.

That said, there is no substitute for doing it and, as they say, “bruising your knuckles” in QI.

Read the full post at hospitalleader.org.

Also on The Hospital Leader…

• From SXSW to SHM: Our Tour to Promote Value Conversations Between Doctors & Patients by Chris Moriates, MD
• It’s Time for a Buzz Cut by Tracy Cardin, ACNP-NC, SFHM
• The Essentials of QI Leadership: A Conversation with Dr. Eric Howell, Part 2 by Jordan Messler, MD, SFHM

Quality improvement became a foundational theme for SHM early in the growth of hospitalists. It’s not a coincidence that many of our leaders, such as Bob Wachter, Win Whitcomb, Greg Maynard, and Mark Williams are QI leaders as well. As hospitalists, we were and are best positioned to impact quality in the hospital.

Eric Howell, MD, of Johns Hopkins Bayview Medical Center in Baltimore serves as the senior physician advisor for SHM’s Center for Quality Improvement, while Jenna Goldstein runs the day-to-day aspects at SHM headquarters. A few months ago, Dr. Howell and I discussed how he started in QI, the role of SHM’s Center, and how hospitalists can receive effective QI training. The following Q&A is edited for conciseness and clarity.

You’ve been a leader in QI for many years; how did you get started in QI?

I trained as an electrical engineer before I went to medical school, which helped me when I went to residency.

When I was a chief at Hopkins Bayview in 1999, there were a number of systems-related issues, including throughput from the emergency department. I became involved with QI because I looked at these systems, thinking they could be better if I used the lens of an engineer. The hospital was very interested in reducing costs, and the physicians, including myself, were interested in making things safer. I was successful because I didn’t just focus on QI but on both sides of the value equation. In the early 2000s, I started to do more and more re-engineering and system improvement projects, and I found them very rewarding. As I showed some success, I was asked to do more.

What you are describing is hands-on training, learning by doing. It seems a lot of your QI training was hands on, as opposed to structured coursework. Was there formal training or is getting your hands dirty in a project the best way to start learning QI?

There is no replacement for actually doing it.

My training was in leadership, which is an integral part of QI. It’s pretty hard to get people to change for quality if you can’t lead them through that change. Initially, I did a lot of work to improve my leadership potential. As faculty, we taught teaching skills, which is a part of leadership. I spent time teaching residents best practices. That’s why I became involved early on with SHM’s Leadership Academy from its start in 2005. I also read a lot of books and still read often to improve my weaknesses. I have my own physicians go through Lean Six Sigma training and get their green belt or black belt.

That said, there is no substitute for doing it and, as they say, “bruising your knuckles” in QI.

Read the full post at hospitalleader.org.

Also on The Hospital Leader…

• From SXSW to SHM: Our Tour to Promote Value Conversations Between Doctors & Patients by Chris Moriates, MD
• It’s Time for a Buzz Cut by Tracy Cardin, ACNP-NC, SFHM
• The Essentials of QI Leadership: A Conversation with Dr. Eric Howell, Part 2 by Jordan Messler, MD, SFHM

Supplemental oxygen did not prevent mortality or rehospitalization among patients with suspected myocardial infarction whose oxygen saturation on room air exceeded 90%, investigators reported.

Rates of all-cause mortality at 1 year were 5% among patients who received supplemental oxygen through an open face mask (6 liters per minute for 6-12 hours) and 5.1% among patients who breathed room air, said Robin Hofmann, MD, of Karolinska Institutet, Stockholm, and his associates. In addition, rehospitalization for MI occurred in 3.8% of patients who received supplemental oxygen and 3.3% of those breathed room air. The findings of the randomized registry-based trial of 6,629 patients were presented at the annual congress of the European Society of Cardiology and published simultaneously in the New England Journal of Medicine.

Guidelines recommend oxygen supplementation in MI, and the practice has persisted for more than a century, but adequately powered trials of hard clinical endpoints are lacking. Above-normal oxygen saturation can potentially worsen reperfusion injury by causing coronary vasoconstriction and increasing production of reactive oxygen species, the researchers noted.

Notably, the Australian Air Versus Oxygen in Myocardial Infarction (AVOID) trial found that oxygen supplementation was associated with larger infarct sizes in patients with ST-segment elevation myocardial infarction, and a recent Cochrane report did not support routine oxygen supplementation for MI.

The current trial enrolled patients aged 30 years and older who had chest pain or shortness of breath lasting less than 6 hours, an oxygen saturation of at least 90% on pulse oximetry, and either electrocardiographic evidence of ischemia or elevated cardiac troponin T or I levels (N Engl J Med. 2017 Aug 28. doi: 10.1056/NEJMoa1706222).

Oxygen therapy lasted a median of 11.6 hours, after which median oxygen saturation levels were 99% in the intervention group and 97% in the control group.

A total of 62 patients (2%) who received oxygen developed hypoxemia, as did 254 patients (8%) who breathed room air. Median highest troponin levels during hospitalization were 946.5 ng per L and 983.0 ng per L, respectively. A total of 166 (5%) patients in the oxygen group and 168 (5.1%) control patients died from any cause by a year after treatment (hazard ratio, 0.97; P = .8). Likewise, supplemental oxygen did not prevent rehospitalization with MI within 1 year (HR, 1.13; P = .3).

“Because power for evaluation of the primary endpoint was lower than anticipated, we cannot completely rule out a small beneficial or detrimental effect of oxygen on mortality,” the researchers wrote. But clinical differences were unlikely, based on the superimposable time-to-event curves through 12 months, the consistent results across subgroups, and the neutral findings on secondary clinical endpoints, they added.

The Swedish Research Council, the Swedish Heart-Lung Foundation, and the Swedish Foundation for Strategic Research funded the study. Dr. Hofmann disclosed research grants from these entities.

Supplemental oxygen did not prevent mortality or rehospitalization among patients with suspected myocardial infarction whose oxygen saturation on room air exceeded 90%, investigators reported.

Rates of all-cause mortality at 1 year were 5% among patients who received supplemental oxygen through an open face mask (6 liters per minute for 6-12 hours) and 5.1% among patients who breathed room air, said Robin Hofmann, MD, of Karolinska Institutet, Stockholm, and his associates. In addition, rehospitalization for MI occurred in 3.8% of patients who received supplemental oxygen and 3.3% of those breathed room air. The findings of the randomized registry-based trial of 6,629 patients were presented at the annual congress of the European Society of Cardiology and published simultaneously in the New England Journal of Medicine.

Guidelines recommend oxygen supplementation in MI, and the practice has persisted for more than a century, but adequately powered trials of hard clinical endpoints are lacking. Above-normal oxygen saturation can potentially worsen reperfusion injury by causing coronary vasoconstriction and increasing production of reactive oxygen species, the researchers noted.

Notably, the Australian Air Versus Oxygen in Myocardial Infarction (AVOID) trial found that oxygen supplementation was associated with larger infarct sizes in patients with ST-segment elevation myocardial infarction, and a recent Cochrane report did not support routine oxygen supplementation for MI.

The current trial enrolled patients aged 30 years and older who had chest pain or shortness of breath lasting less than 6 hours, an oxygen saturation of at least 90% on pulse oximetry, and either electrocardiographic evidence of ischemia or elevated cardiac troponin T or I levels (N Engl J Med. 2017 Aug 28. doi: 10.1056/NEJMoa1706222).

Oxygen therapy lasted a median of 11.6 hours, after which median oxygen saturation levels were 99% in the intervention group and 97% in the control group.

A total of 62 patients (2%) who received oxygen developed hypoxemia, as did 254 patients (8%) who breathed room air. Median highest troponin levels during hospitalization were 946.5 ng per L and 983.0 ng per L, respectively. A total of 166 (5%) patients in the oxygen group and 168 (5.1%) control patients died from any cause by a year after treatment (hazard ratio, 0.97; P = .8). Likewise, supplemental oxygen did not prevent rehospitalization with MI within 1 year (HR, 1.13; P = .3).

“Because power for evaluation of the primary endpoint was lower than anticipated, we cannot completely rule out a small beneficial or detrimental effect of oxygen on mortality,” the researchers wrote. But clinical differences were unlikely, based on the superimposable time-to-event curves through 12 months, the consistent results across subgroups, and the neutral findings on secondary clinical endpoints, they added.

The Swedish Research Council, the Swedish Heart-Lung Foundation, and the Swedish Foundation for Strategic Research funded the study. Dr. Hofmann disclosed research grants from these entities.

Supplemental oxygen did not prevent mortality or rehospitalization among patients with suspected myocardial infarction whose oxygen saturation on room air exceeded 90%, investigators reported.

Rates of all-cause mortality at 1 year were 5% among patients who received supplemental oxygen through an open face mask (6 liters per minute for 6-12 hours) and 5.1% among patients who breathed room air, said Robin Hofmann, MD, of Karolinska Institutet, Stockholm, and his associates. In addition, rehospitalization for MI occurred in 3.8% of patients who received supplemental oxygen and 3.3% of those breathed room air. The findings of the randomized registry-based trial of 6,629 patients were presented at the annual congress of the European Society of Cardiology and published simultaneously in the New England Journal of Medicine.

Guidelines recommend oxygen supplementation in MI, and the practice has persisted for more than a century, but adequately powered trials of hard clinical endpoints are lacking. Above-normal oxygen saturation can potentially worsen reperfusion injury by causing coronary vasoconstriction and increasing production of reactive oxygen species, the researchers noted.

Notably, the Australian Air Versus Oxygen in Myocardial Infarction (AVOID) trial found that oxygen supplementation was associated with larger infarct sizes in patients with ST-segment elevation myocardial infarction, and a recent Cochrane report did not support routine oxygen supplementation for MI.

The current trial enrolled patients aged 30 years and older who had chest pain or shortness of breath lasting less than 6 hours, an oxygen saturation of at least 90% on pulse oximetry, and either electrocardiographic evidence of ischemia or elevated cardiac troponin T or I levels (N Engl J Med. 2017 Aug 28. doi: 10.1056/NEJMoa1706222).

Oxygen therapy lasted a median of 11.6 hours, after which median oxygen saturation levels were 99% in the intervention group and 97% in the control group.

A total of 62 patients (2%) who received oxygen developed hypoxemia, as did 254 patients (8%) who breathed room air. Median highest troponin levels during hospitalization were 946.5 ng per L and 983.0 ng per L, respectively. A total of 166 (5%) patients in the oxygen group and 168 (5.1%) control patients died from any cause by a year after treatment (hazard ratio, 0.97; P = .8). Likewise, supplemental oxygen did not prevent rehospitalization with MI within 1 year (HR, 1.13; P = .3).

“Because power for evaluation of the primary endpoint was lower than anticipated, we cannot completely rule out a small beneficial or detrimental effect of oxygen on mortality,” the researchers wrote. But clinical differences were unlikely, based on the superimposable time-to-event curves through 12 months, the consistent results across subgroups, and the neutral findings on secondary clinical endpoints, they added.

The Swedish Research Council, the Swedish Heart-Lung Foundation, and the Swedish Foundation for Strategic Research funded the study. Dr. Hofmann disclosed research grants from these entities.

Clinical Question: Can a single high-sensitivity cardiac troponin-T (hs-cTnT) reliably rule-out acute myocardial infarction (AMI) to safely enable earlier discharge?

Background: Current practice includes serial measures of hs-cTnT to rule out AMI.

Study Design: A meta-analysis of 11 prospective cohorts at various international locations

Setting: Patients presenting to emergency departments with chest pain.

Dr. Dogra is clinical instructor of medicine in the University of Kentucky division of hospital medicine.

Clinical Question: Can a single high-sensitivity cardiac troponin-T (hs-cTnT) reliably rule-out acute myocardial infarction (AMI) to safely enable earlier discharge?

Background: Current practice includes serial measures of hs-cTnT to rule out AMI.

Study Design: A meta-analysis of 11 prospective cohorts at various international locations

Setting: Patients presenting to emergency departments with chest pain.

Dr. Dogra is clinical instructor of medicine in the University of Kentucky division of hospital medicine.

Clinical Question: Can a single high-sensitivity cardiac troponin-T (hs-cTnT) reliably rule-out acute myocardial infarction (AMI) to safely enable earlier discharge?

Background: Current practice includes serial measures of hs-cTnT to rule out AMI.

Study Design: A meta-analysis of 11 prospective cohorts at various international locations

Setting: Patients presenting to emergency departments with chest pain.

Dr. Dogra is clinical instructor of medicine in the University of Kentucky division of hospital medicine.

Over an 18-month period, small, insertable cardiac monitors detected atrial fibrillation in 29% of previously undiagnosed patients who were at high risk of both AF and stroke, and in 40% of patients over 30 months, according to investigators. The study was presented at the annual congress of the European Society of Cardiology and simultaneously published in JAMA Cardiology.

More than half (56%) of patients consequently started oral anticoagulation therapy, noted James A. Reiffel, MD, of Columbia University College of Physicians and Surgeons, New York, with his associates, for the REVEAL AF investigators.

“The incidence of previously undiagnosed atrial fibrillation may be substantial in patients with risk factors for AF and stroke,” they concluded. “Atrial fibrillation would have gone undetected in most patients had monitoring been limited to 30 days. Further trials regarding the value of detecting subclinical AF and of prophylactic therapies are warranted.”

Atrial fibrillation affects millions worldwide and is associated with older age, hypertension, diabetes, and heart failure, all of which also independently increase the risk of stroke. Minimally invasive prolonged electrocardiographic monitoring with insertable cardiac monitors might help hasten detection and treatment of AF, but diagnostic yield in high-risk patients has been unclear.

In this single-arm, multicenter, prospective study, researchers inserted Reveal XT or Reveal LINQ (Medtronic) cardiac monitors in 385 adults who had either CHAD2 scores of 3, or CHAD2 scores of 2 and one additional risk factor for AF, such as coronary artery disease, sleep apnea, chronic obstructive pulmonary disease, or renal insufficiency. The primary endpoint was AF lasting at least 6 minutes (JAMA Cardiol. 2017 Aug 26. doi: 10.1001/jamacardio.2017.3180). Median follow-up time was 22.5 months. Rates of detecting AF were 6% at 30 days compared with 20% at 6 months, 27% at 12 months, 34% at 24 months, and 40% at 30 months. Patients typically had their first AF episode about 4 months (median, 123 days) after the device was inserted. Among patients who had experienced AF by 18 months, 10% had one or more episodes lasting at least 24 hours, and 72 (56%) were prescribed oral anticoagulation therapy.

The recent PREDATE AF and ASSERT-II studies also found that previously undiagnosed AF was common among high-risk patients, the researchers noted. However, whether anticoagulating patients who have only brief episodes of AF significantly reduces their risk of stroke remains unclear, they added. Three trials (ARTESiA, NOAH, and LOOP) are underway to assess whether oral anticoagulation therapy improves outcomes in patients with device-detected AF.

Medtronic funded the study. Dr. Reiffel and five coinvestigators disclosed consulting for and receiving “modest honoraria” from Medtronic. Two other coinvestigators reported employment with and stock ownership in Medtronic.

Over an 18-month period, small, insertable cardiac monitors detected atrial fibrillation in 29% of previously undiagnosed patients who were at high risk of both AF and stroke, and in 40% of patients over 30 months, according to investigators. The study was presented at the annual congress of the European Society of Cardiology and simultaneously published in JAMA Cardiology.

More than half (56%) of patients consequently started oral anticoagulation therapy, noted James A. Reiffel, MD, of Columbia University College of Physicians and Surgeons, New York, with his associates, for the REVEAL AF investigators.

“The incidence of previously undiagnosed atrial fibrillation may be substantial in patients with risk factors for AF and stroke,” they concluded. “Atrial fibrillation would have gone undetected in most patients had monitoring been limited to 30 days. Further trials regarding the value of detecting subclinical AF and of prophylactic therapies are warranted.”

Atrial fibrillation affects millions worldwide and is associated with older age, hypertension, diabetes, and heart failure, all of which also independently increase the risk of stroke. Minimally invasive prolonged electrocardiographic monitoring with insertable cardiac monitors might help hasten detection and treatment of AF, but diagnostic yield in high-risk patients has been unclear.

In this single-arm, multicenter, prospective study, researchers inserted Reveal XT or Reveal LINQ (Medtronic) cardiac monitors in 385 adults who had either CHAD2 scores of 3, or CHAD2 scores of 2 and one additional risk factor for AF, such as coronary artery disease, sleep apnea, chronic obstructive pulmonary disease, or renal insufficiency. The primary endpoint was AF lasting at least 6 minutes (JAMA Cardiol. 2017 Aug 26. doi: 10.1001/jamacardio.2017.3180). Median follow-up time was 22.5 months. Rates of detecting AF were 6% at 30 days compared with 20% at 6 months, 27% at 12 months, 34% at 24 months, and 40% at 30 months. Patients typically had their first AF episode about 4 months (median, 123 days) after the device was inserted. Among patients who had experienced AF by 18 months, 10% had one or more episodes lasting at least 24 hours, and 72 (56%) were prescribed oral anticoagulation therapy.

The recent PREDATE AF and ASSERT-II studies also found that previously undiagnosed AF was common among high-risk patients, the researchers noted. However, whether anticoagulating patients who have only brief episodes of AF significantly reduces their risk of stroke remains unclear, they added. Three trials (ARTESiA, NOAH, and LOOP) are underway to assess whether oral anticoagulation therapy improves outcomes in patients with device-detected AF.

Medtronic funded the study. Dr. Reiffel and five coinvestigators disclosed consulting for and receiving “modest honoraria” from Medtronic. Two other coinvestigators reported employment with and stock ownership in Medtronic.

Over an 18-month period, small, insertable cardiac monitors detected atrial fibrillation in 29% of previously undiagnosed patients who were at high risk of both AF and stroke, and in 40% of patients over 30 months, according to investigators. The study was presented at the annual congress of the European Society of Cardiology and simultaneously published in JAMA Cardiology.

More than half (56%) of patients consequently started oral anticoagulation therapy, noted James A. Reiffel, MD, of Columbia University College of Physicians and Surgeons, New York, with his associates, for the REVEAL AF investigators.

“The incidence of previously undiagnosed atrial fibrillation may be substantial in patients with risk factors for AF and stroke,” they concluded. “Atrial fibrillation would have gone undetected in most patients had monitoring been limited to 30 days. Further trials regarding the value of detecting subclinical AF and of prophylactic therapies are warranted.”

Atrial fibrillation affects millions worldwide and is associated with older age, hypertension, diabetes, and heart failure, all of which also independently increase the risk of stroke. Minimally invasive prolonged electrocardiographic monitoring with insertable cardiac monitors might help hasten detection and treatment of AF, but diagnostic yield in high-risk patients has been unclear.

In this single-arm, multicenter, prospective study, researchers inserted Reveal XT or Reveal LINQ (Medtronic) cardiac monitors in 385 adults who had either CHAD2 scores of 3, or CHAD2 scores of 2 and one additional risk factor for AF, such as coronary artery disease, sleep apnea, chronic obstructive pulmonary disease, or renal insufficiency. The primary endpoint was AF lasting at least 6 minutes (JAMA Cardiol. 2017 Aug 26. doi: 10.1001/jamacardio.2017.3180). Median follow-up time was 22.5 months. Rates of detecting AF were 6% at 30 days compared with 20% at 6 months, 27% at 12 months, 34% at 24 months, and 40% at 30 months. Patients typically had their first AF episode about 4 months (median, 123 days) after the device was inserted. Among patients who had experienced AF by 18 months, 10% had one or more episodes lasting at least 24 hours, and 72 (56%) were prescribed oral anticoagulation therapy.

The recent PREDATE AF and ASSERT-II studies also found that previously undiagnosed AF was common among high-risk patients, the researchers noted. However, whether anticoagulating patients who have only brief episodes of AF significantly reduces their risk of stroke remains unclear, they added. Three trials (ARTESiA, NOAH, and LOOP) are underway to assess whether oral anticoagulation therapy improves outcomes in patients with device-detected AF.

Medtronic funded the study. Dr. Reiffel and five coinvestigators disclosed consulting for and receiving “modest honoraria” from Medtronic. Two other coinvestigators reported employment with and stock ownership in Medtronic.

Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their 1st, 2nd, and 3rd years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.

I’m always surprised by how much I can learn in a few short weeks. I am now up to full speed with my project studying the utility of bone biopsies in the management of osteomyelitis.

This is a retrospective study, which means I’ll be collecting historical data from patient charts to be used for our analysis. My mentor – Ernie Esquivel, MD – has played an invaluable role in helping me get this project off the ground. He has worked with me on everything from project planning to successfully navigating the ever-confusing institutional review board (IRB) process. He has also provided advice in areas I thought I might actually have more experience, such as data collection and analysis methods.

Cole Hirschfeld is originally from Phoenix. He received undergraduate degrees in finance and entrepreneurship from the University of Arizona and went on to work in the finance industry for 2 years before deciding to change careers and attend medical school. He is now a 4th year medical student at Cornell University, New York, and plans to apply for residency in internal medicine.

Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their 1st, 2nd, and 3rd years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.

I’m always surprised by how much I can learn in a few short weeks. I am now up to full speed with my project studying the utility of bone biopsies in the management of osteomyelitis.

This is a retrospective study, which means I’ll be collecting historical data from patient charts to be used for our analysis. My mentor – Ernie Esquivel, MD – has played an invaluable role in helping me get this project off the ground. He has worked with me on everything from project planning to successfully navigating the ever-confusing institutional review board (IRB) process. He has also provided advice in areas I thought I might actually have more experience, such as data collection and analysis methods.

Cole Hirschfeld is originally from Phoenix. He received undergraduate degrees in finance and entrepreneurship from the University of Arizona and went on to work in the finance industry for 2 years before deciding to change careers and attend medical school. He is now a 4th year medical student at Cornell University, New York, and plans to apply for residency in internal medicine.

Editor’s Note: The Society of Hospital Medicine’s (SHM’s) Physician in Training Committee launched a scholarship program in 2015 for medical students to help transform health care and revolutionize patient care. The program has been expanded for the 2017-18 year, offering two options for students to receive funding and engage in scholarly work during their 1st, 2nd, and 3rd years of medical school. As a part of the program, recipients are required to write about their experience on a biweekly basis.

I’m always surprised by how much I can learn in a few short weeks. I am now up to full speed with my project studying the utility of bone biopsies in the management of osteomyelitis.

This is a retrospective study, which means I’ll be collecting historical data from patient charts to be used for our analysis. My mentor – Ernie Esquivel, MD – has played an invaluable role in helping me get this project off the ground. He has worked with me on everything from project planning to successfully navigating the ever-confusing institutional review board (IRB) process. He has also provided advice in areas I thought I might actually have more experience, such as data collection and analysis methods.

Cole Hirschfeld is originally from Phoenix. He received undergraduate degrees in finance and entrepreneurship from the University of Arizona and went on to work in the finance industry for 2 years before deciding to change careers and attend medical school. He is now a 4th year medical student at Cornell University, New York, and plans to apply for residency in internal medicine.

Clinical Question: What is the frequency of short-term corticosteroid prescriptions and adverse events associated with their use?

Background: Long-term corticosteroid use is usually avoided given risks of complications. Less is known about the risk and frequency of short-term corticosteroid use.

Study Design: Retrospective cohort study and self-controlled case series.

Setting: National U.S. dataset of private insurance claims.

Dr. Gray is assistant professor in the University of Kentucky division of hospital medicine and the Lexington VA Medical Center.

Clinical Question: What is the frequency of short-term corticosteroid prescriptions and adverse events associated with their use?

Background: Long-term corticosteroid use is usually avoided given risks of complications. Less is known about the risk and frequency of short-term corticosteroid use.

Study Design: Retrospective cohort study and self-controlled case series.

Setting: National U.S. dataset of private insurance claims.

Dr. Gray is assistant professor in the University of Kentucky division of hospital medicine and the Lexington VA Medical Center.

Clinical Question: What is the frequency of short-term corticosteroid prescriptions and adverse events associated with their use?

Background: Long-term corticosteroid use is usually avoided given risks of complications. Less is known about the risk and frequency of short-term corticosteroid use.

Study Design: Retrospective cohort study and self-controlled case series.

Setting: National U.S. dataset of private insurance claims.

Dr. Gray is assistant professor in the University of Kentucky division of hospital medicine and the Lexington VA Medical Center.

NASHVILLE, TENN. – Axillary thermometry outperformed both rectal and temporal artery thermometry in 205 newborns aged 12-72 hours in a study performed at the University of North Carolina at Chapel Hill.

The infants had two temperatures taken by each method over a period of 15 minutes, for a total of six readings per child and 1,230 measurements overall. Axillary thermometry proved both accurate and reliable. Rectal thermometry was accurate but less reliable, and temporal thermometry was reliable but less accurate.

M. Alexander Otto/Frontline Medical News

[email protected]

NASHVILLE, TENN. – Axillary thermometry outperformed both rectal and temporal artery thermometry in 205 newborns aged 12-72 hours in a study performed at the University of North Carolina at Chapel Hill.

The infants had two temperatures taken by each method over a period of 15 minutes, for a total of six readings per child and 1,230 measurements overall. Axillary thermometry proved both accurate and reliable. Rectal thermometry was accurate but less reliable, and temporal thermometry was reliable but less accurate.

M. Alexander Otto/Frontline Medical News

[email protected]

NASHVILLE, TENN. – Axillary thermometry outperformed both rectal and temporal artery thermometry in 205 newborns aged 12-72 hours in a study performed at the University of North Carolina at Chapel Hill.

The infants had two temperatures taken by each method over a period of 15 minutes, for a total of six readings per child and 1,230 measurements overall. Axillary thermometry proved both accurate and reliable. Rectal thermometry was accurate but less reliable, and temporal thermometry was reliable but less accurate.

M. Alexander Otto/Frontline Medical News

[email protected]

How hospitalists and other clinicians communicate with patients impacts a patient’s overall experience and satisfaction. But according to the authors of “Communication the Cleveland Way,”¹ a book about how the clinic created and applied communication skills training, “in a culture prioritizing clinical outcomes above all, there can be a tendency to lose sight of one of the most critical aspects of providing effective care: the communication skills that build and foster physician-patient relationships.”

“Studies^2,3 have shown that good communication between doctors and patients and among all caregivers who interface with patients directly results in better clinical outcomes, reduced costs, greater patient satisfaction, and lower rates of physician burnout,” the authors wrote.

How it works

Because a provider’s connection with a patient occurs when a relationship is established, the REDE course focuses on the beginning of the conversation. “It’s important for clinicians to exhibit value and respect through words and actions when welcoming patients,” Dr. Velez said. “Further, instead of guiding the medical interview with a series of close-ended questions like an interrogator would, we invite the use of open-ended questions and setting an agenda for the visit early on, by asking the patient what they wish to discuss.”

Another key component is empathy, which plays a huge role in patient satisfaction. “Learning how to express empathy is very important,” Dr. Velez said. “A patient may not remember all of the medical details discussed, but human interactions, rapport, expressions of care, support, validation, and acknowledgment of emotions tend to be more indelible.”

Dr. Velez notes that decades of literature regarding effective communication have demonstrated improved outcomes. “If trust in a therapeutic relationship is strong, a patient is more likely to follow instructions and have better engagement with their care plan,” he said. “If a clinician ensures that the patient understands the diagnosis and recommendations, then compliance will increase, especially if the plan is tailored to the patient’s goals and perspective.”

One surprising effect of the REDE course was how it improved relationships among professionals. “Many participants have shared that having a day out of one’s normal schedule, not only to learn, but also to share their own experiences, is quite therapeutic,” Dr. Velez said. “We can extend the same communication strategies to team building, interprofessional interactions, and challenging encounters.”
 

Study focuses on comportment and communication

In an effort to define optimal care in hospital medicine, a team from Johns Hopkins Health System set out to establish a metric that would comprehensively assess hospitalists’ comportment (which includes behavior as well as general demeanor) and communication to establish norms and expectations when they saw patients at the bedside.

To perform the study,⁴ chiefs of hospital medicine divisions at five independent hospitals located in Baltimore and Washington identified their most clinically excellent hospitalists. Then, an investigator observed each hospitalist during a routine clinical shift and recorded behaviors believed to be associated with excellent behavior and communication using the hospital medicine comportment and communication observation tool (HMCCOT), said Susrutha Kotwal, MD, assistant professor of medicine at Johns Hopkins University School of Medicine, Baltimore, and lead author. The investigators collected basic demographic information while observing hospitalists for an average of 280 minutes; 26 physicians were observed for 181 separate clinical encounters. Each provider’s mean HMCCOT score was compared with patient satisfaction surveys such as Press Ganey (PG) scores.

Employing the tool

Hospitalists can choose whether to perform behaviors in the HMCCOT themselves, while others may wish to watch other hospitalists to give them feedback tied to specific behaviors. “These simple behaviors are intimately linked to excellent communication and comportment, which can serve as the foundation for delivering patient-centered care,” Dr. Kotwal said.

A positive correlation was found between spending more time with patients and higher HMCCOT scores. “Patients’ complaints about doctors often relate to feeling rushed, that their physicians did not listen to them, or that they did not convey information in a clear manner,” Dr. Kotwal said. “When successfully achieved, patient-centered communication has been associated with improved clinical outcomes, including adherence to recommended treatment and better self-management of chronic disease. Many of the components of the HMCCOT described in our study are at the heart of patient-centered care.”

Dr. Kotwal believes HMCCOT is a better strategy to improve patient satisfaction than patient satisfaction surveys because patients can’t always recall which specific provider saw them. In addition, patients’ recall about the provider may be poor because surveys are sent to patients days after they return home. In addition, patients’ recovery and health outcomes are likely to influence their assessment of the doctor. Finally, feedback is known to be most valuable and transformative when it is specific and given in real time. Therefore, a tool that is able to provide feedback at the encounter level should be more helpful than a tool that offers assessment at the level of the admission, particularly when it can be also delivered immediately after the data are collected.⁵

The study authors conclude that, “Future studies are necessary to determine whether hospitalists of all levels of experience and clinical skill can improve when given data and feedback using the HMCCOT. Larger studies are then needed to assess whether enhancing comportment and communication can truly improve patient satisfaction and clinical outcomes in the hospital. Because hospitalists spend only a small proportion of their clinical time in direct patient care, it is imperative that excellent comportment and communication be established as a goal for every encounter.”
 

The effectiveness of care team rounds at the bedside

Investigators at the UMass Memorial Medical Center, in Worcester, Mass., studied the effectiveness of assembling the entire care team (i.e., physicians, including residents and attendings, nursing, and clinical pharmacy) to round at the patient’s bedside each morning – in lieu of its traditionally separate rounding strategies – on one unit of its academic hospitalist service for an internal quality program, said Patricia Seymour, MD, FAAFP, assistant professor and family medicine hospitalist education director.

Additionally, academic presentations and discussions were all done in front of patients and their families (with a few exceptions) rather than traditional hallway rounds or sit rounds. Over the course of the project, the hospital also offered residents training around physician behaviors that improve patient satisfaction; provided incentives for nurses and residents to work as a team; and created a welcome visit template for the nursing manager and instruments for patients to enhance engagement. Through all of these cycles, the collaborative rounding strategy continued.

Because Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey scores yielded low response rates for the singular test unit and service, the investigators used a validated patient satisfaction instrument and surveyed patients from the intervention group and patients on the same unit who did not experience this collaborative rounding on their day of discharge. The intervention group had higher satisfaction scores at most of the time points. The unit-based HCAHPS scores (not just study patients) improved during this time period.

“We think the strategy of collaborative rounding yielded positive results for obvious reasons – the entire team was on the same page and the information given to the patient was consistent,” said Dr. Seymour, who notes that the study’s findings weren’t published and the project was completed for an internal quality program. “Doctors had an increased understanding about nursing concerns and the nursing staff expressed improved understanding of patients’ care plans.”

Certainly, face time with the patient was extended because much of the academic discussion occurred at the bedside instead of at another physical location without patient awareness, Dr. Seymour said. She believes the strategy boosted patient satisfaction because it was patient centered. “While this rounding strategy is not the most convenient rounding strategy for nurses or doctors, it consolidates the discussion about the patient’s clinical condition and the plan for the day. The patient experiences a strong sense of being cared for by a unified team and receives consistent messaging,” she said.

Also noteworthy is that job satisfaction for residents and nurses improved on the unit over the study time period because of the expected collaboration that was built into the work flow.

Although the facility is no longer using this communication strategy to the same degree, teaching attendings have seen the value of true bedside rounding and continue to teach this skill to learners. “We have had some challenges with geographic cohorting at our institution, which is essential for this type of team-based strategy,” Dr. Seymour said. “Sustainability requires constant encouragement, oversight, and auditing from team leaders which is also challenging and fluctuates with competing demands.”

The results of this study, and others, show that employing tools to improve communication can also result in improved patient satisfaction and experience.

Karen Appold is a medical writer in Pennsylvania.

References

1. Boissy A, Gilligan T. “Communication the Cleveland Clinic Way: How to drive a relationship-centered strategy for superior patient experience.” New York: McGraw-Hill Education. 2016.

2. Weng HC, Hung CM, Liu YT, et al. Associations between emotional intelligence and doctor burnout, job satisfaction and patient satisfaction. Med Educ. 2011;45:835-42.

3. Boissy A, Windover AK, Bokar D, et al. Communication skills training for physicians improves patient satisfaction. J Gen Intern Med. 2016 Jul;31(7):755-761. doi: 10.1007/s11606-016-3597-2. Epub 2016 Feb 26.

4. Kotwal S, Khaliq W, Landis R, Wright S. Developing a comportment and communication tool for use in hospital medicine. J Hosp Med. 2016 Dec;11(12):853-858. doi: 10.1002/jhm.2647. Epub 2016 Aug 13.

5. Fong Ha J, Longnecker N. Doctor-patient communication: a review. Ochsner J. 2010 Spring; 10(1):38-43.

6. Bodenheimer T, Sinsky C. From Triple to Quadruple Aim: care of the patient requires care of the provider. Ann Fam Med. 2014 Nov;12(6): 573-6. doi: 10.1370/afm.1713.

Bonus Content

Clinicians wary of course's worthiness

Before clinicians took Cleveland Clinic’s Relationship Establishment, Development, and Engagement (REDE) course, only 20% strongly agreed that the course would be valuable, whereas afterward 58% strongly agreed that it was indeed valuable. Less than 1% said it wasn’t valuable.⁴ “Most likely clinicians had a preconceived notion about how communication courses go, but they were probably surprised at how much these sessions were equally about them as providers as they were about caring for patients,” said Vicente J. Velez, MD, FACP, FHM, a hospitalist who serves as the director of faculty enrichment for the leadership team of CEHC. “This is the power of relationship-centered care, and also why I think the model has been sustainable.”

Physicians also reported that before taking the course, they had moderate levels of burnout and low levels of empathy. After taking it, burnout metrics (i.e., emotional exhaustion, depersonalization, and personal achievement) and empathy improved significantly. “I observed that most are surprised to find out that empathy is a discreet set of skills that can be learned, practiced, observed, measured, and improved upon,” Dr. Velez said. “If taught in a safe and validating environment and if principles of adult learning are followed, improvement can be optimized and sustained.”

Since the REDE course rolled out in 2012, all attending physicians and medical staff members have been trained in it.
 

Why empathy is preferred over patient-centered care

The Cleveland Clinic intentionally puts a focus on relationship-centered care.

“When there’s an emphasis on patient-centered care, some physicians have a hard time figuring out what to do when the patient wants something that the physician doesn’t feel is appropriate,” said Katie Neuendorf, MD, director for the Center for Excellence in Healthcare Communication. “Patient-centered implies that the patient is always right and that their opinion should win out over the physician’s opinion. In that same scenario, relationship-centered care implies that the relationship should be prioritized, even when there’s disagreement in the plan of care. I can tell my patients that I hear what they are saying, that I empathize with their struggles, that I care about the way the illness is affecting their lives, and that I am here to support them. I can do all of that and still not prescribe a treatment that I feel is inappropriate just because it happens to be what the patient wants.”

How hospitalists and other clinicians communicate with patients impacts a patient’s overall experience and satisfaction. But according to the authors of “Communication the Cleveland Way,”¹ a book about how the clinic created and applied communication skills training, “in a culture prioritizing clinical outcomes above all, there can be a tendency to lose sight of one of the most critical aspects of providing effective care: the communication skills that build and foster physician-patient relationships.”

“Studies^2,3 have shown that good communication between doctors and patients and among all caregivers who interface with patients directly results in better clinical outcomes, reduced costs, greater patient satisfaction, and lower rates of physician burnout,” the authors wrote.

How it works

Because a provider’s connection with a patient occurs when a relationship is established, the REDE course focuses on the beginning of the conversation. “It’s important for clinicians to exhibit value and respect through words and actions when welcoming patients,” Dr. Velez said. “Further, instead of guiding the medical interview with a series of close-ended questions like an interrogator would, we invite the use of open-ended questions and setting an agenda for the visit early on, by asking the patient what they wish to discuss.”

Another key component is empathy, which plays a huge role in patient satisfaction. “Learning how to express empathy is very important,” Dr. Velez said. “A patient may not remember all of the medical details discussed, but human interactions, rapport, expressions of care, support, validation, and acknowledgment of emotions tend to be more indelible.”

Dr. Velez notes that decades of literature regarding effective communication have demonstrated improved outcomes. “If trust in a therapeutic relationship is strong, a patient is more likely to follow instructions and have better engagement with their care plan,” he said. “If a clinician ensures that the patient understands the diagnosis and recommendations, then compliance will increase, especially if the plan is tailored to the patient’s goals and perspective.”

One surprising effect of the REDE course was how it improved relationships among professionals. “Many participants have shared that having a day out of one’s normal schedule, not only to learn, but also to share their own experiences, is quite therapeutic,” Dr. Velez said. “We can extend the same communication strategies to team building, interprofessional interactions, and challenging encounters.”
 

Study focuses on comportment and communication

In an effort to define optimal care in hospital medicine, a team from Johns Hopkins Health System set out to establish a metric that would comprehensively assess hospitalists’ comportment (which includes behavior as well as general demeanor) and communication to establish norms and expectations when they saw patients at the bedside.

To perform the study,⁴ chiefs of hospital medicine divisions at five independent hospitals located in Baltimore and Washington identified their most clinically excellent hospitalists. Then, an investigator observed each hospitalist during a routine clinical shift and recorded behaviors believed to be associated with excellent behavior and communication using the hospital medicine comportment and communication observation tool (HMCCOT), said Susrutha Kotwal, MD, assistant professor of medicine at Johns Hopkins University School of Medicine, Baltimore, and lead author. The investigators collected basic demographic information while observing hospitalists for an average of 280 minutes; 26 physicians were observed for 181 separate clinical encounters. Each provider’s mean HMCCOT score was compared with patient satisfaction surveys such as Press Ganey (PG) scores.

Employing the tool

Hospitalists can choose whether to perform behaviors in the HMCCOT themselves, while others may wish to watch other hospitalists to give them feedback tied to specific behaviors. “These simple behaviors are intimately linked to excellent communication and comportment, which can serve as the foundation for delivering patient-centered care,” Dr. Kotwal said.

A positive correlation was found between spending more time with patients and higher HMCCOT scores. “Patients’ complaints about doctors often relate to feeling rushed, that their physicians did not listen to them, or that they did not convey information in a clear manner,” Dr. Kotwal said. “When successfully achieved, patient-centered communication has been associated with improved clinical outcomes, including adherence to recommended treatment and better self-management of chronic disease. Many of the components of the HMCCOT described in our study are at the heart of patient-centered care.”

Dr. Kotwal believes HMCCOT is a better strategy to improve patient satisfaction than patient satisfaction surveys because patients can’t always recall which specific provider saw them. In addition, patients’ recall about the provider may be poor because surveys are sent to patients days after they return home. In addition, patients’ recovery and health outcomes are likely to influence their assessment of the doctor. Finally, feedback is known to be most valuable and transformative when it is specific and given in real time. Therefore, a tool that is able to provide feedback at the encounter level should be more helpful than a tool that offers assessment at the level of the admission, particularly when it can be also delivered immediately after the data are collected.⁵

The study authors conclude that, “Future studies are necessary to determine whether hospitalists of all levels of experience and clinical skill can improve when given data and feedback using the HMCCOT. Larger studies are then needed to assess whether enhancing comportment and communication can truly improve patient satisfaction and clinical outcomes in the hospital. Because hospitalists spend only a small proportion of their clinical time in direct patient care, it is imperative that excellent comportment and communication be established as a goal for every encounter.”
 

The effectiveness of care team rounds at the bedside

Investigators at the UMass Memorial Medical Center, in Worcester, Mass., studied the effectiveness of assembling the entire care team (i.e., physicians, including residents and attendings, nursing, and clinical pharmacy) to round at the patient’s bedside each morning – in lieu of its traditionally separate rounding strategies – on one unit of its academic hospitalist service for an internal quality program, said Patricia Seymour, MD, FAAFP, assistant professor and family medicine hospitalist education director.

Additionally, academic presentations and discussions were all done in front of patients and their families (with a few exceptions) rather than traditional hallway rounds or sit rounds. Over the course of the project, the hospital also offered residents training around physician behaviors that improve patient satisfaction; provided incentives for nurses and residents to work as a team; and created a welcome visit template for the nursing manager and instruments for patients to enhance engagement. Through all of these cycles, the collaborative rounding strategy continued.

Because Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey scores yielded low response rates for the singular test unit and service, the investigators used a validated patient satisfaction instrument and surveyed patients from the intervention group and patients on the same unit who did not experience this collaborative rounding on their day of discharge. The intervention group had higher satisfaction scores at most of the time points. The unit-based HCAHPS scores (not just study patients) improved during this time period.

“We think the strategy of collaborative rounding yielded positive results for obvious reasons – the entire team was on the same page and the information given to the patient was consistent,” said Dr. Seymour, who notes that the study’s findings weren’t published and the project was completed for an internal quality program. “Doctors had an increased understanding about nursing concerns and the nursing staff expressed improved understanding of patients’ care plans.”

Certainly, face time with the patient was extended because much of the academic discussion occurred at the bedside instead of at another physical location without patient awareness, Dr. Seymour said. She believes the strategy boosted patient satisfaction because it was patient centered. “While this rounding strategy is not the most convenient rounding strategy for nurses or doctors, it consolidates the discussion about the patient’s clinical condition and the plan for the day. The patient experiences a strong sense of being cared for by a unified team and receives consistent messaging,” she said.

Also noteworthy is that job satisfaction for residents and nurses improved on the unit over the study time period because of the expected collaboration that was built into the work flow.

Although the facility is no longer using this communication strategy to the same degree, teaching attendings have seen the value of true bedside rounding and continue to teach this skill to learners. “We have had some challenges with geographic cohorting at our institution, which is essential for this type of team-based strategy,” Dr. Seymour said. “Sustainability requires constant encouragement, oversight, and auditing from team leaders which is also challenging and fluctuates with competing demands.”

The results of this study, and others, show that employing tools to improve communication can also result in improved patient satisfaction and experience.

Karen Appold is a medical writer in Pennsylvania.

References

1. Boissy A, Gilligan T. “Communication the Cleveland Clinic Way: How to drive a relationship-centered strategy for superior patient experience.” New York: McGraw-Hill Education. 2016.

2. Weng HC, Hung CM, Liu YT, et al. Associations between emotional intelligence and doctor burnout, job satisfaction and patient satisfaction. Med Educ. 2011;45:835-42.

3. Boissy A, Windover AK, Bokar D, et al. Communication skills training for physicians improves patient satisfaction. J Gen Intern Med. 2016 Jul;31(7):755-761. doi: 10.1007/s11606-016-3597-2. Epub 2016 Feb 26.

4. Kotwal S, Khaliq W, Landis R, Wright S. Developing a comportment and communication tool for use in hospital medicine. J Hosp Med. 2016 Dec;11(12):853-858. doi: 10.1002/jhm.2647. Epub 2016 Aug 13.

5. Fong Ha J, Longnecker N. Doctor-patient communication: a review. Ochsner J. 2010 Spring; 10(1):38-43.

6. Bodenheimer T, Sinsky C. From Triple to Quadruple Aim: care of the patient requires care of the provider. Ann Fam Med. 2014 Nov;12(6): 573-6. doi: 10.1370/afm.1713.

Bonus Content

Clinicians wary of course's worthiness

Before clinicians took Cleveland Clinic’s Relationship Establishment, Development, and Engagement (REDE) course, only 20% strongly agreed that the course would be valuable, whereas afterward 58% strongly agreed that it was indeed valuable. Less than 1% said it wasn’t valuable.⁴ “Most likely clinicians had a preconceived notion about how communication courses go, but they were probably surprised at how much these sessions were equally about them as providers as they were about caring for patients,” said Vicente J. Velez, MD, FACP, FHM, a hospitalist who serves as the director of faculty enrichment for the leadership team of CEHC. “This is the power of relationship-centered care, and also why I think the model has been sustainable.”

Physicians also reported that before taking the course, they had moderate levels of burnout and low levels of empathy. After taking it, burnout metrics (i.e., emotional exhaustion, depersonalization, and personal achievement) and empathy improved significantly. “I observed that most are surprised to find out that empathy is a discreet set of skills that can be learned, practiced, observed, measured, and improved upon,” Dr. Velez said. “If taught in a safe and validating environment and if principles of adult learning are followed, improvement can be optimized and sustained.”

Since the REDE course rolled out in 2012, all attending physicians and medical staff members have been trained in it.
 

Why empathy is preferred over patient-centered care

The Cleveland Clinic intentionally puts a focus on relationship-centered care.

“When there’s an emphasis on patient-centered care, some physicians have a hard time figuring out what to do when the patient wants something that the physician doesn’t feel is appropriate,” said Katie Neuendorf, MD, director for the Center for Excellence in Healthcare Communication. “Patient-centered implies that the patient is always right and that their opinion should win out over the physician’s opinion. In that same scenario, relationship-centered care implies that the relationship should be prioritized, even when there’s disagreement in the plan of care. I can tell my patients that I hear what they are saying, that I empathize with their struggles, that I care about the way the illness is affecting their lives, and that I am here to support them. I can do all of that and still not prescribe a treatment that I feel is inappropriate just because it happens to be what the patient wants.”

How hospitalists and other clinicians communicate with patients impacts a patient’s overall experience and satisfaction. But according to the authors of “Communication the Cleveland Way,”¹ a book about how the clinic created and applied communication skills training, “in a culture prioritizing clinical outcomes above all, there can be a tendency to lose sight of one of the most critical aspects of providing effective care: the communication skills that build and foster physician-patient relationships.”

“Studies^2,3 have shown that good communication between doctors and patients and among all caregivers who interface with patients directly results in better clinical outcomes, reduced costs, greater patient satisfaction, and lower rates of physician burnout,” the authors wrote.

How it works

Because a provider’s connection with a patient occurs when a relationship is established, the REDE course focuses on the beginning of the conversation. “It’s important for clinicians to exhibit value and respect through words and actions when welcoming patients,” Dr. Velez said. “Further, instead of guiding the medical interview with a series of close-ended questions like an interrogator would, we invite the use of open-ended questions and setting an agenda for the visit early on, by asking the patient what they wish to discuss.”

Another key component is empathy, which plays a huge role in patient satisfaction. “Learning how to express empathy is very important,” Dr. Velez said. “A patient may not remember all of the medical details discussed, but human interactions, rapport, expressions of care, support, validation, and acknowledgment of emotions tend to be more indelible.”

Dr. Velez notes that decades of literature regarding effective communication have demonstrated improved outcomes. “If trust in a therapeutic relationship is strong, a patient is more likely to follow instructions and have better engagement with their care plan,” he said. “If a clinician ensures that the patient understands the diagnosis and recommendations, then compliance will increase, especially if the plan is tailored to the patient’s goals and perspective.”

One surprising effect of the REDE course was how it improved relationships among professionals. “Many participants have shared that having a day out of one’s normal schedule, not only to learn, but also to share their own experiences, is quite therapeutic,” Dr. Velez said. “We can extend the same communication strategies to team building, interprofessional interactions, and challenging encounters.”
 

Study focuses on comportment and communication

In an effort to define optimal care in hospital medicine, a team from Johns Hopkins Health System set out to establish a metric that would comprehensively assess hospitalists’ comportment (which includes behavior as well as general demeanor) and communication to establish norms and expectations when they saw patients at the bedside.

To perform the study,⁴ chiefs of hospital medicine divisions at five independent hospitals located in Baltimore and Washington identified their most clinically excellent hospitalists. Then, an investigator observed each hospitalist during a routine clinical shift and recorded behaviors believed to be associated with excellent behavior and communication using the hospital medicine comportment and communication observation tool (HMCCOT), said Susrutha Kotwal, MD, assistant professor of medicine at Johns Hopkins University School of Medicine, Baltimore, and lead author. The investigators collected basic demographic information while observing hospitalists for an average of 280 minutes; 26 physicians were observed for 181 separate clinical encounters. Each provider’s mean HMCCOT score was compared with patient satisfaction surveys such as Press Ganey (PG) scores.

Employing the tool

Hospitalists can choose whether to perform behaviors in the HMCCOT themselves, while others may wish to watch other hospitalists to give them feedback tied to specific behaviors. “These simple behaviors are intimately linked to excellent communication and comportment, which can serve as the foundation for delivering patient-centered care,” Dr. Kotwal said.

A positive correlation was found between spending more time with patients and higher HMCCOT scores. “Patients’ complaints about doctors often relate to feeling rushed, that their physicians did not listen to them, or that they did not convey information in a clear manner,” Dr. Kotwal said. “When successfully achieved, patient-centered communication has been associated with improved clinical outcomes, including adherence to recommended treatment and better self-management of chronic disease. Many of the components of the HMCCOT described in our study are at the heart of patient-centered care.”

Dr. Kotwal believes HMCCOT is a better strategy to improve patient satisfaction than patient satisfaction surveys because patients can’t always recall which specific provider saw them. In addition, patients’ recall about the provider may be poor because surveys are sent to patients days after they return home. In addition, patients’ recovery and health outcomes are likely to influence their assessment of the doctor. Finally, feedback is known to be most valuable and transformative when it is specific and given in real time. Therefore, a tool that is able to provide feedback at the encounter level should be more helpful than a tool that offers assessment at the level of the admission, particularly when it can be also delivered immediately after the data are collected.⁵

The study authors conclude that, “Future studies are necessary to determine whether hospitalists of all levels of experience and clinical skill can improve when given data and feedback using the HMCCOT. Larger studies are then needed to assess whether enhancing comportment and communication can truly improve patient satisfaction and clinical outcomes in the hospital. Because hospitalists spend only a small proportion of their clinical time in direct patient care, it is imperative that excellent comportment and communication be established as a goal for every encounter.”
 

The effectiveness of care team rounds at the bedside

Investigators at the UMass Memorial Medical Center, in Worcester, Mass., studied the effectiveness of assembling the entire care team (i.e., physicians, including residents and attendings, nursing, and clinical pharmacy) to round at the patient’s bedside each morning – in lieu of its traditionally separate rounding strategies – on one unit of its academic hospitalist service for an internal quality program, said Patricia Seymour, MD, FAAFP, assistant professor and family medicine hospitalist education director.

Additionally, academic presentations and discussions were all done in front of patients and their families (with a few exceptions) rather than traditional hallway rounds or sit rounds. Over the course of the project, the hospital also offered residents training around physician behaviors that improve patient satisfaction; provided incentives for nurses and residents to work as a team; and created a welcome visit template for the nursing manager and instruments for patients to enhance engagement. Through all of these cycles, the collaborative rounding strategy continued.

Because Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey scores yielded low response rates for the singular test unit and service, the investigators used a validated patient satisfaction instrument and surveyed patients from the intervention group and patients on the same unit who did not experience this collaborative rounding on their day of discharge. The intervention group had higher satisfaction scores at most of the time points. The unit-based HCAHPS scores (not just study patients) improved during this time period.

“We think the strategy of collaborative rounding yielded positive results for obvious reasons – the entire team was on the same page and the information given to the patient was consistent,” said Dr. Seymour, who notes that the study’s findings weren’t published and the project was completed for an internal quality program. “Doctors had an increased understanding about nursing concerns and the nursing staff expressed improved understanding of patients’ care plans.”

Certainly, face time with the patient was extended because much of the academic discussion occurred at the bedside instead of at another physical location without patient awareness, Dr. Seymour said. She believes the strategy boosted patient satisfaction because it was patient centered. “While this rounding strategy is not the most convenient rounding strategy for nurses or doctors, it consolidates the discussion about the patient’s clinical condition and the plan for the day. The patient experiences a strong sense of being cared for by a unified team and receives consistent messaging,” she said.

Also noteworthy is that job satisfaction for residents and nurses improved on the unit over the study time period because of the expected collaboration that was built into the work flow.

Although the facility is no longer using this communication strategy to the same degree, teaching attendings have seen the value of true bedside rounding and continue to teach this skill to learners. “We have had some challenges with geographic cohorting at our institution, which is essential for this type of team-based strategy,” Dr. Seymour said. “Sustainability requires constant encouragement, oversight, and auditing from team leaders which is also challenging and fluctuates with competing demands.”

The results of this study, and others, show that employing tools to improve communication can also result in improved patient satisfaction and experience.

Karen Appold is a medical writer in Pennsylvania.

References

1. Boissy A, Gilligan T. “Communication the Cleveland Clinic Way: How to drive a relationship-centered strategy for superior patient experience.” New York: McGraw-Hill Education. 2016.

2. Weng HC, Hung CM, Liu YT, et al. Associations between emotional intelligence and doctor burnout, job satisfaction and patient satisfaction. Med Educ. 2011;45:835-42.

3. Boissy A, Windover AK, Bokar D, et al. Communication skills training for physicians improves patient satisfaction. J Gen Intern Med. 2016 Jul;31(7):755-761. doi: 10.1007/s11606-016-3597-2. Epub 2016 Feb 26.

4. Kotwal S, Khaliq W, Landis R, Wright S. Developing a comportment and communication tool for use in hospital medicine. J Hosp Med. 2016 Dec;11(12):853-858. doi: 10.1002/jhm.2647. Epub 2016 Aug 13.

5. Fong Ha J, Longnecker N. Doctor-patient communication: a review. Ochsner J. 2010 Spring; 10(1):38-43.

6. Bodenheimer T, Sinsky C. From Triple to Quadruple Aim: care of the patient requires care of the provider. Ann Fam Med. 2014 Nov;12(6): 573-6. doi: 10.1370/afm.1713.

Bonus Content

Clinicians wary of course's worthiness

Before clinicians took Cleveland Clinic’s Relationship Establishment, Development, and Engagement (REDE) course, only 20% strongly agreed that the course would be valuable, whereas afterward 58% strongly agreed that it was indeed valuable. Less than 1% said it wasn’t valuable.⁴ “Most likely clinicians had a preconceived notion about how communication courses go, but they were probably surprised at how much these sessions were equally about them as providers as they were about caring for patients,” said Vicente J. Velez, MD, FACP, FHM, a hospitalist who serves as the director of faculty enrichment for the leadership team of CEHC. “This is the power of relationship-centered care, and also why I think the model has been sustainable.”

Physicians also reported that before taking the course, they had moderate levels of burnout and low levels of empathy. After taking it, burnout metrics (i.e., emotional exhaustion, depersonalization, and personal achievement) and empathy improved significantly. “I observed that most are surprised to find out that empathy is a discreet set of skills that can be learned, practiced, observed, measured, and improved upon,” Dr. Velez said. “If taught in a safe and validating environment and if principles of adult learning are followed, improvement can be optimized and sustained.”

Since the REDE course rolled out in 2012, all attending physicians and medical staff members have been trained in it.
 

Why empathy is preferred over patient-centered care

The Cleveland Clinic intentionally puts a focus on relationship-centered care.

“When there’s an emphasis on patient-centered care, some physicians have a hard time figuring out what to do when the patient wants something that the physician doesn’t feel is appropriate,” said Katie Neuendorf, MD, director for the Center for Excellence in Healthcare Communication. “Patient-centered implies that the patient is always right and that their opinion should win out over the physician’s opinion. In that same scenario, relationship-centered care implies that the relationship should be prioritized, even when there’s disagreement in the plan of care. I can tell my patients that I hear what they are saying, that I empathize with their struggles, that I care about the way the illness is affecting their lives, and that I am here to support them. I can do all of that and still not prescribe a treatment that I feel is inappropriate just because it happens to be what the patient wants.”

Global mortality due to rheumatic heart disease fell by about 48% during a recent 25-year-period, but some of the poorest areas of the world were left behind, according to a report in the New England Journal of Medicine.

Those regions included Oceania, South Asia, and central sub-Saharan Africa, where rheumatic heart disease remains endemic, wrote David A. Watkins, MD, MPH, of the University of Washington, Seattle, and his coinvestigators. “We estimate that 10 persons per 1,000 population living in South Asia and central sub-Saharan Africa and 15 persons per 1,000 population in Oceania were living with rheumatic heart disease in the year 2015,” they wrote. “Improvements in the measurement of the burden of rheumatic heart disease will assist in planning for its control and will help identify countries where further investments are needed.”

Global mortality due to rheumatic heart disease fell by about 48% during a recent 25-year-period, but some of the poorest areas of the world were left behind, according to a report in the New England Journal of Medicine.

Those regions included Oceania, South Asia, and central sub-Saharan Africa, where rheumatic heart disease remains endemic, wrote David A. Watkins, MD, MPH, of the University of Washington, Seattle, and his coinvestigators. “We estimate that 10 persons per 1,000 population living in South Asia and central sub-Saharan Africa and 15 persons per 1,000 population in Oceania were living with rheumatic heart disease in the year 2015,” they wrote. “Improvements in the measurement of the burden of rheumatic heart disease will assist in planning for its control and will help identify countries where further investments are needed.”

Global mortality due to rheumatic heart disease fell by about 48% during a recent 25-year-period, but some of the poorest areas of the world were left behind, according to a report in the New England Journal of Medicine.

Those regions included Oceania, South Asia, and central sub-Saharan Africa, where rheumatic heart disease remains endemic, wrote David A. Watkins, MD, MPH, of the University of Washington, Seattle, and his coinvestigators. “We estimate that 10 persons per 1,000 population living in South Asia and central sub-Saharan Africa and 15 persons per 1,000 population in Oceania were living with rheumatic heart disease in the year 2015,” they wrote. “Improvements in the measurement of the burden of rheumatic heart disease will assist in planning for its control and will help identify countries where further investments are needed.”