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Using shock index in the ED to predict hospital admission and inpatient mortality
CLINICAL QUESTION: Can shock index (SI) in the ED predict the likelihood for hospital admission and inpatient mortality?
BACKGROUND: SI is defined as heart rate divided by systolic blood pressure. It is postulated to have an inverse relationship to cardiac output. SI has been studied as a prognostic metric of poor outcomes in patients with myocardial infarction, gastrointestinal hemorrhage, sepsis, and trauma. There are no large studies on SI in the general ED population.
SETTING: Academic tertiary care center.
SYNOPSIS: All ED patients over 18 years of age over a 12-month period were included in the study for a total of 58,633 charts. Charts were excluded if the patient presented in cardiac arrest, left prior to full evaluation in the ED, or had an incomplete or absent first set of vital signs. Likelihood ratio (LR) values of greater than 5 and 10 were considered moderate and large increases in the outcomes, respectively. Authors found SI greater than 1.2 had a positive LR of 11.69 for admission to the hospital and a positive LR of 5.82 for inpatient mortality.
This study identified potential thresholds for SI but did not validate them. Whether SI would be a useful tool for triage remains unanswered.
BOTTOM LINE: Initial SI greater than 1.2 at presentation to the ED was associated with increased likelihood of hospital admission and inpatient mortality.
CITATIONS: Balhara KS, Hsieh YH, Hamade B, et al. Clinical metrics in emergency medicine: the shock index and the probability of hospital admission and inpatient mortality. Emerg Med J. 2017 Feb;34(2):89-94.
Dr. Dietsche is a clinical instructor, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
CLINICAL QUESTION: Can shock index (SI) in the ED predict the likelihood for hospital admission and inpatient mortality?
BACKGROUND: SI is defined as heart rate divided by systolic blood pressure. It is postulated to have an inverse relationship to cardiac output. SI has been studied as a prognostic metric of poor outcomes in patients with myocardial infarction, gastrointestinal hemorrhage, sepsis, and trauma. There are no large studies on SI in the general ED population.
SETTING: Academic tertiary care center.
SYNOPSIS: All ED patients over 18 years of age over a 12-month period were included in the study for a total of 58,633 charts. Charts were excluded if the patient presented in cardiac arrest, left prior to full evaluation in the ED, or had an incomplete or absent first set of vital signs. Likelihood ratio (LR) values of greater than 5 and 10 were considered moderate and large increases in the outcomes, respectively. Authors found SI greater than 1.2 had a positive LR of 11.69 for admission to the hospital and a positive LR of 5.82 for inpatient mortality.
This study identified potential thresholds for SI but did not validate them. Whether SI would be a useful tool for triage remains unanswered.
BOTTOM LINE: Initial SI greater than 1.2 at presentation to the ED was associated with increased likelihood of hospital admission and inpatient mortality.
CITATIONS: Balhara KS, Hsieh YH, Hamade B, et al. Clinical metrics in emergency medicine: the shock index and the probability of hospital admission and inpatient mortality. Emerg Med J. 2017 Feb;34(2):89-94.
Dr. Dietsche is a clinical instructor, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
CLINICAL QUESTION: Can shock index (SI) in the ED predict the likelihood for hospital admission and inpatient mortality?
BACKGROUND: SI is defined as heart rate divided by systolic blood pressure. It is postulated to have an inverse relationship to cardiac output. SI has been studied as a prognostic metric of poor outcomes in patients with myocardial infarction, gastrointestinal hemorrhage, sepsis, and trauma. There are no large studies on SI in the general ED population.
SETTING: Academic tertiary care center.
SYNOPSIS: All ED patients over 18 years of age over a 12-month period were included in the study for a total of 58,633 charts. Charts were excluded if the patient presented in cardiac arrest, left prior to full evaluation in the ED, or had an incomplete or absent first set of vital signs. Likelihood ratio (LR) values of greater than 5 and 10 were considered moderate and large increases in the outcomes, respectively. Authors found SI greater than 1.2 had a positive LR of 11.69 for admission to the hospital and a positive LR of 5.82 for inpatient mortality.
This study identified potential thresholds for SI but did not validate them. Whether SI would be a useful tool for triage remains unanswered.
BOTTOM LINE: Initial SI greater than 1.2 at presentation to the ED was associated with increased likelihood of hospital admission and inpatient mortality.
CITATIONS: Balhara KS, Hsieh YH, Hamade B, et al. Clinical metrics in emergency medicine: the shock index and the probability of hospital admission and inpatient mortality. Emerg Med J. 2017 Feb;34(2):89-94.
Dr. Dietsche is a clinical instructor, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
Enlisting social networks for better health outcomes
As a hospitalist, you typically have little, if any, contact with patients outside the hospital and, at most, you’ll only spend a couple of hours a year in front of any particular patient. The vast majority of the determinants of your patients’ health occur when you’re not there.
In a commentary in the New England Journal of Medicine entitled “Engineering Social Incentives for Health,” lead author David A. Asch, MD, MBA, addresses that issue.1
“The motivation for the piece is that the people who are in a position to influence a patient’s health are their friends and family, and yet so much of how we have structured health care is between a clinician and a patient,” he says. “We often fail to engage the people in patients’ everyday lives, who can be quite willing partners in improving health care. There are all sorts of things they can do to help patients with hard-to-control diabetes or ... heart failure, or anything that might have put them in the hospital in the first place.”
The column describes a ladder of social engineering strategies, from very simple to complex. One example on the simple end might be to help a patient remember a daily medication by having him place the medication bottle where his partner can see him taking – or not taking – it. (The alternative is that medications are taken in a private place, such in the bathroom, where no one might be watching over the routine to keep the patient on track.)
Moving up the ladder, a hospitalist might help set up a network of other patients with heart failure, so that they can help each other in a kind of peer mentorship.
“These peer-to-peer connections might require Web-based platforms or social support groups, so that kind of activity is a lot more complicated, but the general theme is: Can hospitalists think about ways to constructively engage the social networks that already surround patients, so they don’t need to invoke the health system to do it?”
It’s long been known that people with more social support do better: People who are married do better; people who have more friends do better. “Up until now, it’s just been an observation,” Dr. Asch says. “I think we’re at a point where we could begin to prescribe social support in the way we might prescribe a diuretic. I’d like to try it out at least. I think that’s the call to action.”
Reference
1. Asch D, Rosin R. Engineering social incentives for health. NEJM. 2016;375:2511-2513.
As a hospitalist, you typically have little, if any, contact with patients outside the hospital and, at most, you’ll only spend a couple of hours a year in front of any particular patient. The vast majority of the determinants of your patients’ health occur when you’re not there.
In a commentary in the New England Journal of Medicine entitled “Engineering Social Incentives for Health,” lead author David A. Asch, MD, MBA, addresses that issue.1
“The motivation for the piece is that the people who are in a position to influence a patient’s health are their friends and family, and yet so much of how we have structured health care is between a clinician and a patient,” he says. “We often fail to engage the people in patients’ everyday lives, who can be quite willing partners in improving health care. There are all sorts of things they can do to help patients with hard-to-control diabetes or ... heart failure, or anything that might have put them in the hospital in the first place.”
The column describes a ladder of social engineering strategies, from very simple to complex. One example on the simple end might be to help a patient remember a daily medication by having him place the medication bottle where his partner can see him taking – or not taking – it. (The alternative is that medications are taken in a private place, such in the bathroom, where no one might be watching over the routine to keep the patient on track.)
Moving up the ladder, a hospitalist might help set up a network of other patients with heart failure, so that they can help each other in a kind of peer mentorship.
“These peer-to-peer connections might require Web-based platforms or social support groups, so that kind of activity is a lot more complicated, but the general theme is: Can hospitalists think about ways to constructively engage the social networks that already surround patients, so they don’t need to invoke the health system to do it?”
It’s long been known that people with more social support do better: People who are married do better; people who have more friends do better. “Up until now, it’s just been an observation,” Dr. Asch says. “I think we’re at a point where we could begin to prescribe social support in the way we might prescribe a diuretic. I’d like to try it out at least. I think that’s the call to action.”
Reference
1. Asch D, Rosin R. Engineering social incentives for health. NEJM. 2016;375:2511-2513.
As a hospitalist, you typically have little, if any, contact with patients outside the hospital and, at most, you’ll only spend a couple of hours a year in front of any particular patient. The vast majority of the determinants of your patients’ health occur when you’re not there.
In a commentary in the New England Journal of Medicine entitled “Engineering Social Incentives for Health,” lead author David A. Asch, MD, MBA, addresses that issue.1
“The motivation for the piece is that the people who are in a position to influence a patient’s health are their friends and family, and yet so much of how we have structured health care is between a clinician and a patient,” he says. “We often fail to engage the people in patients’ everyday lives, who can be quite willing partners in improving health care. There are all sorts of things they can do to help patients with hard-to-control diabetes or ... heart failure, or anything that might have put them in the hospital in the first place.”
The column describes a ladder of social engineering strategies, from very simple to complex. One example on the simple end might be to help a patient remember a daily medication by having him place the medication bottle where his partner can see him taking – or not taking – it. (The alternative is that medications are taken in a private place, such in the bathroom, where no one might be watching over the routine to keep the patient on track.)
Moving up the ladder, a hospitalist might help set up a network of other patients with heart failure, so that they can help each other in a kind of peer mentorship.
“These peer-to-peer connections might require Web-based platforms or social support groups, so that kind of activity is a lot more complicated, but the general theme is: Can hospitalists think about ways to constructively engage the social networks that already surround patients, so they don’t need to invoke the health system to do it?”
It’s long been known that people with more social support do better: People who are married do better; people who have more friends do better. “Up until now, it’s just been an observation,” Dr. Asch says. “I think we’re at a point where we could begin to prescribe social support in the way we might prescribe a diuretic. I’d like to try it out at least. I think that’s the call to action.”
Reference
1. Asch D, Rosin R. Engineering social incentives for health. NEJM. 2016;375:2511-2513.
Sneak Peek: Journal of Hospital Medicine
BACKGROUND: Readmissions after hospitalization for pneumonia are common, but the few risk-prediction models have poor to modest predictive ability. Data routinely collected in the EHR may improve prediction.
DESIGN: Observational cohort study using backward-stepwise selection and cross validation.
SUBJECTS: Consecutive pneumonia hospitalizations from six diverse hospitals in north Texas from 2009 to 2010.
MEASURES: All-cause, nonelective, 30-day readmissions, ascertained from 75 regional hospitals.
RESULTS: Of 1,463 patients, 13.6% were readmitted. The first-day, pneumonia-specific model included sociodemographic factors, prior hospitalizations, thrombocytosis, and a modified pneumonia severity index. The full-stay model included disposition status, vital sign instabilities on discharge, and an updated pneumonia severity index calculated using values from the day of discharge as additional predictors. The full-stay, pneumonia-specific model outperformed the first-day model (C-statistic, 0.731 vs. 0.695; P = .02; net reclassification index = 0.08). Compared with a validated multicondition readmission model, the Centers for Medicare & Medicaid Services pneumonia model, and two commonly used pneumonia severity of illness scores, the full-stay pneumonia-specific model had better discrimination (C-statistic, 0.604-0.681; P less than 0.01 for all comparisons), predicted a broader range of risk, and better reclassified individuals by their true risk (net reclassification index range, 0.09-0.18).
CONCLUSIONS: EHR data collected from the entire hospitalization can accurately predict readmission risk among patients hospitalized for pneumonia. This approach outperforms a first-day, pneumonia-specific model, the Centers for Medicare & Medicaid Services pneumonia model, and two commonly used pneumonia severity of illness scores.
Also In JHM This Month
Evaluating automated rules for rapid response system alarm triggers in medical and surgical patients
AUTHORS: Santiago Romero-Brufau, MD; Bruce W. Morlan, MS; Matthew Johnson, MPH; Joel Hickman; Lisa L. Kirkland, MD; James M. Naessens, ScD; Jeanne Huddleston, MD, FACP, FHM
Prognosticating with the Hospital-Patient One-year Mortality Risk score using information abstracted from the medical record
AUTHORS: Genevieve Casey, MD, and Carl van Walraven, MD, FRCPC, MSc
Automating venous thromboembolism risk calculation using electronic health record data upon hospital admission: The Automated Padua Prediction Score
AUTHORS: Pierre Elias, MD; Raman Khanna, MD; Adams Dudley, MD, MBA; Jason Davies, MD, PhD; Ronald Jacolbia, MSN; Kara McArthur, BA; Andrew D. Auerbach, MD, MPH, SFHM
The value of ultrasound in cellulitis to rule out deep venous thrombosis
AUTHORS: Hyung J. Cho, MD, and Andrew S. Dunn, MD, SFHM
Hospital medicine and perioperative care: A framework for high quality, high value collaborative care
AUTHORS: Rachel E. Thompson, MD, MPH, SFHM; Kurt Pfeifer, MD, FHM; Paul Grant, MD, SFHM; Cornelia Taylor, MD; Barbara Slawski, MD, FACP, MS, SFHM; Christopher Whinney, MD, FACP, FHM; Laurence Wellikson, MD, MHM; Amir K. Jaffer, MD, MBA, SFHM
BACKGROUND: Readmissions after hospitalization for pneumonia are common, but the few risk-prediction models have poor to modest predictive ability. Data routinely collected in the EHR may improve prediction.
DESIGN: Observational cohort study using backward-stepwise selection and cross validation.
SUBJECTS: Consecutive pneumonia hospitalizations from six diverse hospitals in north Texas from 2009 to 2010.
MEASURES: All-cause, nonelective, 30-day readmissions, ascertained from 75 regional hospitals.
RESULTS: Of 1,463 patients, 13.6% were readmitted. The first-day, pneumonia-specific model included sociodemographic factors, prior hospitalizations, thrombocytosis, and a modified pneumonia severity index. The full-stay model included disposition status, vital sign instabilities on discharge, and an updated pneumonia severity index calculated using values from the day of discharge as additional predictors. The full-stay, pneumonia-specific model outperformed the first-day model (C-statistic, 0.731 vs. 0.695; P = .02; net reclassification index = 0.08). Compared with a validated multicondition readmission model, the Centers for Medicare & Medicaid Services pneumonia model, and two commonly used pneumonia severity of illness scores, the full-stay pneumonia-specific model had better discrimination (C-statistic, 0.604-0.681; P less than 0.01 for all comparisons), predicted a broader range of risk, and better reclassified individuals by their true risk (net reclassification index range, 0.09-0.18).
CONCLUSIONS: EHR data collected from the entire hospitalization can accurately predict readmission risk among patients hospitalized for pneumonia. This approach outperforms a first-day, pneumonia-specific model, the Centers for Medicare & Medicaid Services pneumonia model, and two commonly used pneumonia severity of illness scores.
Also In JHM This Month
Evaluating automated rules for rapid response system alarm triggers in medical and surgical patients
AUTHORS: Santiago Romero-Brufau, MD; Bruce W. Morlan, MS; Matthew Johnson, MPH; Joel Hickman; Lisa L. Kirkland, MD; James M. Naessens, ScD; Jeanne Huddleston, MD, FACP, FHM
Prognosticating with the Hospital-Patient One-year Mortality Risk score using information abstracted from the medical record
AUTHORS: Genevieve Casey, MD, and Carl van Walraven, MD, FRCPC, MSc
Automating venous thromboembolism risk calculation using electronic health record data upon hospital admission: The Automated Padua Prediction Score
AUTHORS: Pierre Elias, MD; Raman Khanna, MD; Adams Dudley, MD, MBA; Jason Davies, MD, PhD; Ronald Jacolbia, MSN; Kara McArthur, BA; Andrew D. Auerbach, MD, MPH, SFHM
The value of ultrasound in cellulitis to rule out deep venous thrombosis
AUTHORS: Hyung J. Cho, MD, and Andrew S. Dunn, MD, SFHM
Hospital medicine and perioperative care: A framework for high quality, high value collaborative care
AUTHORS: Rachel E. Thompson, MD, MPH, SFHM; Kurt Pfeifer, MD, FHM; Paul Grant, MD, SFHM; Cornelia Taylor, MD; Barbara Slawski, MD, FACP, MS, SFHM; Christopher Whinney, MD, FACP, FHM; Laurence Wellikson, MD, MHM; Amir K. Jaffer, MD, MBA, SFHM
BACKGROUND: Readmissions after hospitalization for pneumonia are common, but the few risk-prediction models have poor to modest predictive ability. Data routinely collected in the EHR may improve prediction.
DESIGN: Observational cohort study using backward-stepwise selection and cross validation.
SUBJECTS: Consecutive pneumonia hospitalizations from six diverse hospitals in north Texas from 2009 to 2010.
MEASURES: All-cause, nonelective, 30-day readmissions, ascertained from 75 regional hospitals.
RESULTS: Of 1,463 patients, 13.6% were readmitted. The first-day, pneumonia-specific model included sociodemographic factors, prior hospitalizations, thrombocytosis, and a modified pneumonia severity index. The full-stay model included disposition status, vital sign instabilities on discharge, and an updated pneumonia severity index calculated using values from the day of discharge as additional predictors. The full-stay, pneumonia-specific model outperformed the first-day model (C-statistic, 0.731 vs. 0.695; P = .02; net reclassification index = 0.08). Compared with a validated multicondition readmission model, the Centers for Medicare & Medicaid Services pneumonia model, and two commonly used pneumonia severity of illness scores, the full-stay pneumonia-specific model had better discrimination (C-statistic, 0.604-0.681; P less than 0.01 for all comparisons), predicted a broader range of risk, and better reclassified individuals by their true risk (net reclassification index range, 0.09-0.18).
CONCLUSIONS: EHR data collected from the entire hospitalization can accurately predict readmission risk among patients hospitalized for pneumonia. This approach outperforms a first-day, pneumonia-specific model, the Centers for Medicare & Medicaid Services pneumonia model, and two commonly used pneumonia severity of illness scores.
Also In JHM This Month
Evaluating automated rules for rapid response system alarm triggers in medical and surgical patients
AUTHORS: Santiago Romero-Brufau, MD; Bruce W. Morlan, MS; Matthew Johnson, MPH; Joel Hickman; Lisa L. Kirkland, MD; James M. Naessens, ScD; Jeanne Huddleston, MD, FACP, FHM
Prognosticating with the Hospital-Patient One-year Mortality Risk score using information abstracted from the medical record
AUTHORS: Genevieve Casey, MD, and Carl van Walraven, MD, FRCPC, MSc
Automating venous thromboembolism risk calculation using electronic health record data upon hospital admission: The Automated Padua Prediction Score
AUTHORS: Pierre Elias, MD; Raman Khanna, MD; Adams Dudley, MD, MBA; Jason Davies, MD, PhD; Ronald Jacolbia, MSN; Kara McArthur, BA; Andrew D. Auerbach, MD, MPH, SFHM
The value of ultrasound in cellulitis to rule out deep venous thrombosis
AUTHORS: Hyung J. Cho, MD, and Andrew S. Dunn, MD, SFHM
Hospital medicine and perioperative care: A framework for high quality, high value collaborative care
AUTHORS: Rachel E. Thompson, MD, MPH, SFHM; Kurt Pfeifer, MD, FHM; Paul Grant, MD, SFHM; Cornelia Taylor, MD; Barbara Slawski, MD, FACP, MS, SFHM; Christopher Whinney, MD, FACP, FHM; Laurence Wellikson, MD, MHM; Amir K. Jaffer, MD, MBA, SFHM
Dabigatran crushes warfarin for AF ablation
Washington – Uninterrupted dabigatran for periprocedural anticoagulation in patients undergoing catheter ablation for atrial fibrillation proved far superior to uninterrupted warfarin – the current standard – in the randomized multicenter RE-CIRCUIT trial, Hugh Calkins, MD, reported at the annual meeting of the American College of Cardiology.
The primary study endpoint – the incidence of major bleeding events from the time of the first femoral puncture at the procedure’s start through the subsequent 8 weeks – occurred in 1.6% of the dabigatran (Pradaxa) group and 6.9% of the warfarin group, for an absolute 5.9% reduction in risk and a 77% relative risk reduction favoring the novel anticoagulant.
“This trial will definitely affect my own practice, and I think it will quickly affect the practices of electrophysiologists around the world,” declared Dr. Calkins, professor of cardiology and medicine and director of the clinical electrophysiology laboratory and the arrhythmia service at Johns Hopkins University, Baltimore.
RE-CIRCUIT (Randomized Evaluation of Dabigatran Etexilate Compared to Warfarin in Pulmonary Vein Ablation: Assessment of an Uninterrupted Periprocedural Anticoagulation Strategy) was a multicenter, prospective, international trial conducted in 635 atrial fibrillation (AF) patients who underwent catheter ablation at 104 sites. The trial was of necessity open label because of the need for frequent adjustments of warfarin dosing; however, outcome assessment was carried out by a blinded panel of six cardiologists and three neurologists.
Standard practice among AF ablationists is to continue oral anticoagulation periprocedurally because prior studies have convincingly shown that periprocedural interruption of warfarin in an effort to reduce bleeding results in a sharply increased risk of periprocedural stroke. So participants in RE-CIRCUIT were randomized to 4-8 weeks of uninterrupted anticoagulation with either dabigatran at 150 mg b.i.d. or warfarin with a target international normalized ratio (INR) of 2.0-3.0 prior to the ablation procedure, during it, and for 8 weeks afterward, at which time an individualized decision was made as to whether to stop or continue the drug.
Major bleeding events were defined by the International Society on Thrombosis and Hemostatis criteria. Most of these bleeds occurred within the first day or two after the procedure. Pericardial tamponades and groin hematomas were significantly less common with dabigatran.
The incidence of minor bleeding events was similar, at around 18% in the two treatment arms. No strokes or systemic embolisms occurred in the study. One patient on warfarin experienced a transient ischemic attack.
Dr. Calkins elaborated on why RE-CIRCUIT will change clinical practice: “A stroke is a terrible thing during an AF procedure and cardiac tamponade is the most common cause of death from the procedure. And now we have high-quality data showing that if you perform this procedure on uninterrupted dabigatran, the risk of stroke and other systemic embolic events is extremely low, and the rate of major bleeding was 77% less.
“Plus, the logistics of warfarin are a pain,” he continued. “If the patient presents on the day of ablation with an INR that’s too high, the procedure is canceled, and if they present with an INR that’s too low and the procedure is carried out, it’s done so with an increased stroke risk.”
Dr. Calkins said he suspects the sharp reduction in major bleeding events during and after AF catheter ablation is a class effect shared by the other NOACs. Studies with those agents are ongoing. But for now, the unique availability of an immediate reversal agent in the form of idarucizumab (Praxbind) for dabigatran in the event of uncontrolled major bleeding is a source of reassurance for operators and patients alike. The antidote was never required in RE-CIRCUIT, though, the cardiologist noted.
Discussant William G. Stevenson, MD, called the trial “informative and helpful.”
“Something we’ve all been struggling with was that some concern was earlier raised that dabigatran might be associated with more thromboembolic events in this scenario. This study clearly refutes that concern,” observed Dr. Stevenson, director of the clinical cardiac electrophysiology program at Brigham and Women’s Hospital and professor of medicine at Harvard Medical School, both in Boston.
Dr. Stevenson wondered whether the outcome differences between the two study groups could be explained by differences in operator techniques and tools. That’s highly unlikely, Dr. Calkins replied. Randomization was done patient by patient, not center by center.
Then why the big difference in major bleeding complications? Dr. Stevenson asked.
“It may be that, if you poke a hole when a patient is on a more forgiving anticoagulant like dabigatran, the bleeding doesn’t persist and turn into a tamponade, whereas if you poke a hole on warfarin it turns into a bigger problem,” Dr. Calkins responded. “When you think about it, warfarin really impacts the whole coagulation cascade through factors VII, IX, and X, so multiple coagulation factors are rendered impotent, whereas dabigatran is a direct thrombin inhibitor, so you’re selectively knocking out just one component of the coagulation cascade. It provides more leeway in preventing a small hole from turning into a big effusion,” he said.
The RE-CIRCUIT trial was funded by Boehringer Ingelheim. Dr. Calkins reported receiving lecture fees from that company and from Medtronic, and serving as a consultant to Medtronic, Abbott Medical, and AtriCure.
Simultaneously with Dr. Calkins’ presentation at ACC 17, the RE-CIRCUIT study was published online (N Engl J Med. 2017 Mar 19. doi: 10.1056/NEJMoa1701005).
Washington – Uninterrupted dabigatran for periprocedural anticoagulation in patients undergoing catheter ablation for atrial fibrillation proved far superior to uninterrupted warfarin – the current standard – in the randomized multicenter RE-CIRCUIT trial, Hugh Calkins, MD, reported at the annual meeting of the American College of Cardiology.
The primary study endpoint – the incidence of major bleeding events from the time of the first femoral puncture at the procedure’s start through the subsequent 8 weeks – occurred in 1.6% of the dabigatran (Pradaxa) group and 6.9% of the warfarin group, for an absolute 5.9% reduction in risk and a 77% relative risk reduction favoring the novel anticoagulant.
“This trial will definitely affect my own practice, and I think it will quickly affect the practices of electrophysiologists around the world,” declared Dr. Calkins, professor of cardiology and medicine and director of the clinical electrophysiology laboratory and the arrhythmia service at Johns Hopkins University, Baltimore.
RE-CIRCUIT (Randomized Evaluation of Dabigatran Etexilate Compared to Warfarin in Pulmonary Vein Ablation: Assessment of an Uninterrupted Periprocedural Anticoagulation Strategy) was a multicenter, prospective, international trial conducted in 635 atrial fibrillation (AF) patients who underwent catheter ablation at 104 sites. The trial was of necessity open label because of the need for frequent adjustments of warfarin dosing; however, outcome assessment was carried out by a blinded panel of six cardiologists and three neurologists.
Standard practice among AF ablationists is to continue oral anticoagulation periprocedurally because prior studies have convincingly shown that periprocedural interruption of warfarin in an effort to reduce bleeding results in a sharply increased risk of periprocedural stroke. So participants in RE-CIRCUIT were randomized to 4-8 weeks of uninterrupted anticoagulation with either dabigatran at 150 mg b.i.d. or warfarin with a target international normalized ratio (INR) of 2.0-3.0 prior to the ablation procedure, during it, and for 8 weeks afterward, at which time an individualized decision was made as to whether to stop or continue the drug.
Major bleeding events were defined by the International Society on Thrombosis and Hemostatis criteria. Most of these bleeds occurred within the first day or two after the procedure. Pericardial tamponades and groin hematomas were significantly less common with dabigatran.
The incidence of minor bleeding events was similar, at around 18% in the two treatment arms. No strokes or systemic embolisms occurred in the study. One patient on warfarin experienced a transient ischemic attack.
Dr. Calkins elaborated on why RE-CIRCUIT will change clinical practice: “A stroke is a terrible thing during an AF procedure and cardiac tamponade is the most common cause of death from the procedure. And now we have high-quality data showing that if you perform this procedure on uninterrupted dabigatran, the risk of stroke and other systemic embolic events is extremely low, and the rate of major bleeding was 77% less.
“Plus, the logistics of warfarin are a pain,” he continued. “If the patient presents on the day of ablation with an INR that’s too high, the procedure is canceled, and if they present with an INR that’s too low and the procedure is carried out, it’s done so with an increased stroke risk.”
Dr. Calkins said he suspects the sharp reduction in major bleeding events during and after AF catheter ablation is a class effect shared by the other NOACs. Studies with those agents are ongoing. But for now, the unique availability of an immediate reversal agent in the form of idarucizumab (Praxbind) for dabigatran in the event of uncontrolled major bleeding is a source of reassurance for operators and patients alike. The antidote was never required in RE-CIRCUIT, though, the cardiologist noted.
Discussant William G. Stevenson, MD, called the trial “informative and helpful.”
“Something we’ve all been struggling with was that some concern was earlier raised that dabigatran might be associated with more thromboembolic events in this scenario. This study clearly refutes that concern,” observed Dr. Stevenson, director of the clinical cardiac electrophysiology program at Brigham and Women’s Hospital and professor of medicine at Harvard Medical School, both in Boston.
Dr. Stevenson wondered whether the outcome differences between the two study groups could be explained by differences in operator techniques and tools. That’s highly unlikely, Dr. Calkins replied. Randomization was done patient by patient, not center by center.
Then why the big difference in major bleeding complications? Dr. Stevenson asked.
“It may be that, if you poke a hole when a patient is on a more forgiving anticoagulant like dabigatran, the bleeding doesn’t persist and turn into a tamponade, whereas if you poke a hole on warfarin it turns into a bigger problem,” Dr. Calkins responded. “When you think about it, warfarin really impacts the whole coagulation cascade through factors VII, IX, and X, so multiple coagulation factors are rendered impotent, whereas dabigatran is a direct thrombin inhibitor, so you’re selectively knocking out just one component of the coagulation cascade. It provides more leeway in preventing a small hole from turning into a big effusion,” he said.
The RE-CIRCUIT trial was funded by Boehringer Ingelheim. Dr. Calkins reported receiving lecture fees from that company and from Medtronic, and serving as a consultant to Medtronic, Abbott Medical, and AtriCure.
Simultaneously with Dr. Calkins’ presentation at ACC 17, the RE-CIRCUIT study was published online (N Engl J Med. 2017 Mar 19. doi: 10.1056/NEJMoa1701005).
Washington – Uninterrupted dabigatran for periprocedural anticoagulation in patients undergoing catheter ablation for atrial fibrillation proved far superior to uninterrupted warfarin – the current standard – in the randomized multicenter RE-CIRCUIT trial, Hugh Calkins, MD, reported at the annual meeting of the American College of Cardiology.
The primary study endpoint – the incidence of major bleeding events from the time of the first femoral puncture at the procedure’s start through the subsequent 8 weeks – occurred in 1.6% of the dabigatran (Pradaxa) group and 6.9% of the warfarin group, for an absolute 5.9% reduction in risk and a 77% relative risk reduction favoring the novel anticoagulant.
“This trial will definitely affect my own practice, and I think it will quickly affect the practices of electrophysiologists around the world,” declared Dr. Calkins, professor of cardiology and medicine and director of the clinical electrophysiology laboratory and the arrhythmia service at Johns Hopkins University, Baltimore.
RE-CIRCUIT (Randomized Evaluation of Dabigatran Etexilate Compared to Warfarin in Pulmonary Vein Ablation: Assessment of an Uninterrupted Periprocedural Anticoagulation Strategy) was a multicenter, prospective, international trial conducted in 635 atrial fibrillation (AF) patients who underwent catheter ablation at 104 sites. The trial was of necessity open label because of the need for frequent adjustments of warfarin dosing; however, outcome assessment was carried out by a blinded panel of six cardiologists and three neurologists.
Standard practice among AF ablationists is to continue oral anticoagulation periprocedurally because prior studies have convincingly shown that periprocedural interruption of warfarin in an effort to reduce bleeding results in a sharply increased risk of periprocedural stroke. So participants in RE-CIRCUIT were randomized to 4-8 weeks of uninterrupted anticoagulation with either dabigatran at 150 mg b.i.d. or warfarin with a target international normalized ratio (INR) of 2.0-3.0 prior to the ablation procedure, during it, and for 8 weeks afterward, at which time an individualized decision was made as to whether to stop or continue the drug.
Major bleeding events were defined by the International Society on Thrombosis and Hemostatis criteria. Most of these bleeds occurred within the first day or two after the procedure. Pericardial tamponades and groin hematomas were significantly less common with dabigatran.
The incidence of minor bleeding events was similar, at around 18% in the two treatment arms. No strokes or systemic embolisms occurred in the study. One patient on warfarin experienced a transient ischemic attack.
Dr. Calkins elaborated on why RE-CIRCUIT will change clinical practice: “A stroke is a terrible thing during an AF procedure and cardiac tamponade is the most common cause of death from the procedure. And now we have high-quality data showing that if you perform this procedure on uninterrupted dabigatran, the risk of stroke and other systemic embolic events is extremely low, and the rate of major bleeding was 77% less.
“Plus, the logistics of warfarin are a pain,” he continued. “If the patient presents on the day of ablation with an INR that’s too high, the procedure is canceled, and if they present with an INR that’s too low and the procedure is carried out, it’s done so with an increased stroke risk.”
Dr. Calkins said he suspects the sharp reduction in major bleeding events during and after AF catheter ablation is a class effect shared by the other NOACs. Studies with those agents are ongoing. But for now, the unique availability of an immediate reversal agent in the form of idarucizumab (Praxbind) for dabigatran in the event of uncontrolled major bleeding is a source of reassurance for operators and patients alike. The antidote was never required in RE-CIRCUIT, though, the cardiologist noted.
Discussant William G. Stevenson, MD, called the trial “informative and helpful.”
“Something we’ve all been struggling with was that some concern was earlier raised that dabigatran might be associated with more thromboembolic events in this scenario. This study clearly refutes that concern,” observed Dr. Stevenson, director of the clinical cardiac electrophysiology program at Brigham and Women’s Hospital and professor of medicine at Harvard Medical School, both in Boston.
Dr. Stevenson wondered whether the outcome differences between the two study groups could be explained by differences in operator techniques and tools. That’s highly unlikely, Dr. Calkins replied. Randomization was done patient by patient, not center by center.
Then why the big difference in major bleeding complications? Dr. Stevenson asked.
“It may be that, if you poke a hole when a patient is on a more forgiving anticoagulant like dabigatran, the bleeding doesn’t persist and turn into a tamponade, whereas if you poke a hole on warfarin it turns into a bigger problem,” Dr. Calkins responded. “When you think about it, warfarin really impacts the whole coagulation cascade through factors VII, IX, and X, so multiple coagulation factors are rendered impotent, whereas dabigatran is a direct thrombin inhibitor, so you’re selectively knocking out just one component of the coagulation cascade. It provides more leeway in preventing a small hole from turning into a big effusion,” he said.
The RE-CIRCUIT trial was funded by Boehringer Ingelheim. Dr. Calkins reported receiving lecture fees from that company and from Medtronic, and serving as a consultant to Medtronic, Abbott Medical, and AtriCure.
Simultaneously with Dr. Calkins’ presentation at ACC 17, the RE-CIRCUIT study was published online (N Engl J Med. 2017 Mar 19. doi: 10.1056/NEJMoa1701005).
At ACC 17
Key clinical point:
Major finding: The incidence of major bleeding events in conjunction with catheter ablation of atrial fibrillation was reduced by 77% in patients on periprocedural dabigatran compared with those on warfarin.
Data source: A randomized multicenter prospective international trial of 635 patients who underwent catheter ablation for atrial fibrillation supported by uninterrupted oral anticoagulation.
Disclosures: The RE-CIRCUIT trial was funded by Boehringer Ingelheim. Dr. Calkins reported receiving lecture fees from that company and from Medtronic, and serving as a consultant to Medtronic, Abbott Medical, and AtriCure.
Perioperative pharmacological thromboprophylaxis in patients with cancer: a systematic review and meta-analysis
Clinical Question: What are the benefits and harms of perioperative pharmacological thromboprophylaxis in cancer patients undergoing surgery?
Background: Both cancer and surgery increase the risk of venous thromboembolism (VTE). In postsurgical patients with cancer, the benefits and harms of anticoagulation remain unknown.
Synopsis: Thirty-nine trials were deemed eligible for inclusion in the meta-analysis. Twenty-five of these were prospective and 14 were retrospective. The overall incidence of deep venous thrombosis (DVT) and pulmonary embolism was 0.9% (across 20 studies) and 0.3% (across 19 studies), respectively. Pharmacologic prophylaxis overall reduced DVT incidence (0.5% vs. 1.2%; relative risk, 0.51; P = .03). Subgroup analysis demonstrated this was significant for abdominal/pelvic surgeries and with low molecular weight heparin. Six studies compared duration of standard prophylaxis (10 days) with extended prophylaxis (4 weeks), with a lower VTE rate in the extended group. Bleeding events were noted in 13 studies and pharmacologic prophylaxis significantly increased bleeding risk (2.7% vs. 8%; RR, 2.51; P less than .0001).
Bottom Line: Perioperative pharmacologic prophylaxis reduces DVT risk in patients with cancer, with greatest risk reduction seen in patients undergoing abdominal/pelvic surgeries. This comes at the cost of increased bleeding complications.
Citations: Guo Q, Huang B, Zhao J, et al. Perioperative pharmacological thromboprophylaxis in patients with cancer: a systematic review and meta-analysis. Ann Surg. 2016 Nov. doi: 10.1097/SLA.0000000000002074.
Dr. Patil is a clinical instructor, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
Clinical Question: What are the benefits and harms of perioperative pharmacological thromboprophylaxis in cancer patients undergoing surgery?
Background: Both cancer and surgery increase the risk of venous thromboembolism (VTE). In postsurgical patients with cancer, the benefits and harms of anticoagulation remain unknown.
Synopsis: Thirty-nine trials were deemed eligible for inclusion in the meta-analysis. Twenty-five of these were prospective and 14 were retrospective. The overall incidence of deep venous thrombosis (DVT) and pulmonary embolism was 0.9% (across 20 studies) and 0.3% (across 19 studies), respectively. Pharmacologic prophylaxis overall reduced DVT incidence (0.5% vs. 1.2%; relative risk, 0.51; P = .03). Subgroup analysis demonstrated this was significant for abdominal/pelvic surgeries and with low molecular weight heparin. Six studies compared duration of standard prophylaxis (10 days) with extended prophylaxis (4 weeks), with a lower VTE rate in the extended group. Bleeding events were noted in 13 studies and pharmacologic prophylaxis significantly increased bleeding risk (2.7% vs. 8%; RR, 2.51; P less than .0001).
Bottom Line: Perioperative pharmacologic prophylaxis reduces DVT risk in patients with cancer, with greatest risk reduction seen in patients undergoing abdominal/pelvic surgeries. This comes at the cost of increased bleeding complications.
Citations: Guo Q, Huang B, Zhao J, et al. Perioperative pharmacological thromboprophylaxis in patients with cancer: a systematic review and meta-analysis. Ann Surg. 2016 Nov. doi: 10.1097/SLA.0000000000002074.
Dr. Patil is a clinical instructor, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
Clinical Question: What are the benefits and harms of perioperative pharmacological thromboprophylaxis in cancer patients undergoing surgery?
Background: Both cancer and surgery increase the risk of venous thromboembolism (VTE). In postsurgical patients with cancer, the benefits and harms of anticoagulation remain unknown.
Synopsis: Thirty-nine trials were deemed eligible for inclusion in the meta-analysis. Twenty-five of these were prospective and 14 were retrospective. The overall incidence of deep venous thrombosis (DVT) and pulmonary embolism was 0.9% (across 20 studies) and 0.3% (across 19 studies), respectively. Pharmacologic prophylaxis overall reduced DVT incidence (0.5% vs. 1.2%; relative risk, 0.51; P = .03). Subgroup analysis demonstrated this was significant for abdominal/pelvic surgeries and with low molecular weight heparin. Six studies compared duration of standard prophylaxis (10 days) with extended prophylaxis (4 weeks), with a lower VTE rate in the extended group. Bleeding events were noted in 13 studies and pharmacologic prophylaxis significantly increased bleeding risk (2.7% vs. 8%; RR, 2.51; P less than .0001).
Bottom Line: Perioperative pharmacologic prophylaxis reduces DVT risk in patients with cancer, with greatest risk reduction seen in patients undergoing abdominal/pelvic surgeries. This comes at the cost of increased bleeding complications.
Citations: Guo Q, Huang B, Zhao J, et al. Perioperative pharmacological thromboprophylaxis in patients with cancer: a systematic review and meta-analysis. Ann Surg. 2016 Nov. doi: 10.1097/SLA.0000000000002074.
Dr. Patil is a clinical instructor, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
Readmission rates after passage of the hospital readmissions reduction program
Clinical Question: Did hospitals receiving the highest penalties for readmissions have accelerated improvement in this metric after passage of Medicare Hospital Readmissions Reduction Program (HRRP)?
Background: Medicare passed the HRRP to incentivize reductions in readmission rates. The impact of penalties on relative hospital improvement rates remains unknown.
Setting: Query of national Medicare Provider Analysis and Review files.
Synopsis: 2,868 hospitals were identified as candidates for analysis and were stratified into four risk groups based on penalty size under HRRP: highest-performing, average-performing, low-performing, and lowest-performing. The primary outcomes were hospital-specific, 30-day, all-cause risk-standardized readmission rates (RSRRs) for patients discharged with acute MI, HF, or pneumonia. The investigators separated data into a pre-law period and post-law period. They fitted a logistic regression model to pre-law RSRRs and developed a piecewise linear model on post-law RSRRs with pre-law data as the dependent variable. All hospital groups had reductions in RSRRs, with the lowest quartile demonstrating greatest improvement.
Bottom Line: HRRP has resulted in reductions in RSRRs with greatest improvement in hospitals with lowest pre-law performance.
Citations: Wasfy JH, Zigler CM, Choirat C, et al. Readmission rates after passage of the hospital readmissions reduction program: a pre-post analysis. Ann Intern Med. 2017 Mar;166(5):324-31.
Dr. Patil is a clinical instructor, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
Clinical Question: Did hospitals receiving the highest penalties for readmissions have accelerated improvement in this metric after passage of Medicare Hospital Readmissions Reduction Program (HRRP)?
Background: Medicare passed the HRRP to incentivize reductions in readmission rates. The impact of penalties on relative hospital improvement rates remains unknown.
Setting: Query of national Medicare Provider Analysis and Review files.
Synopsis: 2,868 hospitals were identified as candidates for analysis and were stratified into four risk groups based on penalty size under HRRP: highest-performing, average-performing, low-performing, and lowest-performing. The primary outcomes were hospital-specific, 30-day, all-cause risk-standardized readmission rates (RSRRs) for patients discharged with acute MI, HF, or pneumonia. The investigators separated data into a pre-law period and post-law period. They fitted a logistic regression model to pre-law RSRRs and developed a piecewise linear model on post-law RSRRs with pre-law data as the dependent variable. All hospital groups had reductions in RSRRs, with the lowest quartile demonstrating greatest improvement.
Bottom Line: HRRP has resulted in reductions in RSRRs with greatest improvement in hospitals with lowest pre-law performance.
Citations: Wasfy JH, Zigler CM, Choirat C, et al. Readmission rates after passage of the hospital readmissions reduction program: a pre-post analysis. Ann Intern Med. 2017 Mar;166(5):324-31.
Dr. Patil is a clinical instructor, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
Clinical Question: Did hospitals receiving the highest penalties for readmissions have accelerated improvement in this metric after passage of Medicare Hospital Readmissions Reduction Program (HRRP)?
Background: Medicare passed the HRRP to incentivize reductions in readmission rates. The impact of penalties on relative hospital improvement rates remains unknown.
Setting: Query of national Medicare Provider Analysis and Review files.
Synopsis: 2,868 hospitals were identified as candidates for analysis and were stratified into four risk groups based on penalty size under HRRP: highest-performing, average-performing, low-performing, and lowest-performing. The primary outcomes were hospital-specific, 30-day, all-cause risk-standardized readmission rates (RSRRs) for patients discharged with acute MI, HF, or pneumonia. The investigators separated data into a pre-law period and post-law period. They fitted a logistic regression model to pre-law RSRRs and developed a piecewise linear model on post-law RSRRs with pre-law data as the dependent variable. All hospital groups had reductions in RSRRs, with the lowest quartile demonstrating greatest improvement.
Bottom Line: HRRP has resulted in reductions in RSRRs with greatest improvement in hospitals with lowest pre-law performance.
Citations: Wasfy JH, Zigler CM, Choirat C, et al. Readmission rates after passage of the hospital readmissions reduction program: a pre-post analysis. Ann Intern Med. 2017 Mar;166(5):324-31.
Dr. Patil is a clinical instructor, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
HM17: Plenaries – Conway and DeSalvo
The first two plenary addresses at HM17 are focused on policy at a time when the dynamically evolving U.S. health care delivery system may seem daunting, opaque, and labyrinthine.
Some might view the health care landscape as hopelessly confusing. Yet both of the keynote speakers use the same word for what they hope to leave their listeners with: optimism.
“Though it feels uncertain in the headlines, the reality is that the health care world feels pretty united in that we need to continue the progress we’ve made on moving away from the fee-for-service model and to let people practice medicine the way they want – to work better as teams and focus on patients and outcomes,” said Karen DeSalvo, MD, MPH, MSc, former acting assistant secretary for health in the U.S. Department of Health and Human Services (HHS) and former national coordinator for health information technology.
“I would view it as an opportunity as well,” said Dr. Conway, who still moonlights as a pediatric academic hospitalist on weekends in greater Washington, D.C. “I think the pieces are coming together. Everything from data, to new payment models, to the MACRA Medicare Physician payment legislation, really suggests a time of positive change.”
Dr. DeSalvo, a former political appointee, joined HHS as the national coordinator for health information technology in 2014 and soon thereafter assumed the acting assistant secretary role. Dr. Conway has attained one of the country’s highest-ranking public health care jobs since joining CMS in 2011. He retained the top post at CMS while President Donald Trump’s nominee to lead the agency, Seema Verma, awaited a confirmation hearing before the U.S. Senate. Dr. Conway’s prior title was principal deputy administrator and CMS chief medical officer.
“I don’t want people to lose sight of the fact that there’s this entire care system that everybody’s working and innovating in every day, trying to find more efficient, effective ways to get better outcomes,” she said. “Hospitalists, quite frankly, have been leading that for their entire existence. They really understand in great granular detail what it takes.”
Dr. DeSalvo believes that the progress of the past 5 years has established a path that must be followed. The public sector move away from fee-for-service has combined with emerging technology platforms to create a new age where physicians and insurers can judge, in real time, how well care is working.
“We’re now in a feedback loop where we can say – ‘When we’ve built a care system like this or when we pay this way, we are actually seeing improved outcomes’ – and change doesn’t take as long,” Dr. DeSalvo said.
Dr. Conway, whose working title for his speech is “Health care System Transformation,” said hospitalists should be encouraged by how well the field has already adapted to the proliferation of accountable care organizations (ACOs), value-based purchasing (VBP), alternative payment models (APM), and the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. He noted that, as innovations lead to better and more coordinated patient care, hospitalists, patients, and hospitals would all benefit.
“I want to leave people with the idea that value-based payment innovation and delivery system reform will continue to be critical aspects of improving our health system,” he said. “I also want hospitalists to continue to stay engaged with these new payment models, help lead them, and provide better patient care as a part of them.”
The first two plenary addresses at HM17 are focused on policy at a time when the dynamically evolving U.S. health care delivery system may seem daunting, opaque, and labyrinthine.
Some might view the health care landscape as hopelessly confusing. Yet both of the keynote speakers use the same word for what they hope to leave their listeners with: optimism.
“Though it feels uncertain in the headlines, the reality is that the health care world feels pretty united in that we need to continue the progress we’ve made on moving away from the fee-for-service model and to let people practice medicine the way they want – to work better as teams and focus on patients and outcomes,” said Karen DeSalvo, MD, MPH, MSc, former acting assistant secretary for health in the U.S. Department of Health and Human Services (HHS) and former national coordinator for health information technology.
“I would view it as an opportunity as well,” said Dr. Conway, who still moonlights as a pediatric academic hospitalist on weekends in greater Washington, D.C. “I think the pieces are coming together. Everything from data, to new payment models, to the MACRA Medicare Physician payment legislation, really suggests a time of positive change.”
Dr. DeSalvo, a former political appointee, joined HHS as the national coordinator for health information technology in 2014 and soon thereafter assumed the acting assistant secretary role. Dr. Conway has attained one of the country’s highest-ranking public health care jobs since joining CMS in 2011. He retained the top post at CMS while President Donald Trump’s nominee to lead the agency, Seema Verma, awaited a confirmation hearing before the U.S. Senate. Dr. Conway’s prior title was principal deputy administrator and CMS chief medical officer.
“I don’t want people to lose sight of the fact that there’s this entire care system that everybody’s working and innovating in every day, trying to find more efficient, effective ways to get better outcomes,” she said. “Hospitalists, quite frankly, have been leading that for their entire existence. They really understand in great granular detail what it takes.”
Dr. DeSalvo believes that the progress of the past 5 years has established a path that must be followed. The public sector move away from fee-for-service has combined with emerging technology platforms to create a new age where physicians and insurers can judge, in real time, how well care is working.
“We’re now in a feedback loop where we can say – ‘When we’ve built a care system like this or when we pay this way, we are actually seeing improved outcomes’ – and change doesn’t take as long,” Dr. DeSalvo said.
Dr. Conway, whose working title for his speech is “Health care System Transformation,” said hospitalists should be encouraged by how well the field has already adapted to the proliferation of accountable care organizations (ACOs), value-based purchasing (VBP), alternative payment models (APM), and the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. He noted that, as innovations lead to better and more coordinated patient care, hospitalists, patients, and hospitals would all benefit.
“I want to leave people with the idea that value-based payment innovation and delivery system reform will continue to be critical aspects of improving our health system,” he said. “I also want hospitalists to continue to stay engaged with these new payment models, help lead them, and provide better patient care as a part of them.”
The first two plenary addresses at HM17 are focused on policy at a time when the dynamically evolving U.S. health care delivery system may seem daunting, opaque, and labyrinthine.
Some might view the health care landscape as hopelessly confusing. Yet both of the keynote speakers use the same word for what they hope to leave their listeners with: optimism.
“Though it feels uncertain in the headlines, the reality is that the health care world feels pretty united in that we need to continue the progress we’ve made on moving away from the fee-for-service model and to let people practice medicine the way they want – to work better as teams and focus on patients and outcomes,” said Karen DeSalvo, MD, MPH, MSc, former acting assistant secretary for health in the U.S. Department of Health and Human Services (HHS) and former national coordinator for health information technology.
“I would view it as an opportunity as well,” said Dr. Conway, who still moonlights as a pediatric academic hospitalist on weekends in greater Washington, D.C. “I think the pieces are coming together. Everything from data, to new payment models, to the MACRA Medicare Physician payment legislation, really suggests a time of positive change.”
Dr. DeSalvo, a former political appointee, joined HHS as the national coordinator for health information technology in 2014 and soon thereafter assumed the acting assistant secretary role. Dr. Conway has attained one of the country’s highest-ranking public health care jobs since joining CMS in 2011. He retained the top post at CMS while President Donald Trump’s nominee to lead the agency, Seema Verma, awaited a confirmation hearing before the U.S. Senate. Dr. Conway’s prior title was principal deputy administrator and CMS chief medical officer.
“I don’t want people to lose sight of the fact that there’s this entire care system that everybody’s working and innovating in every day, trying to find more efficient, effective ways to get better outcomes,” she said. “Hospitalists, quite frankly, have been leading that for their entire existence. They really understand in great granular detail what it takes.”
Dr. DeSalvo believes that the progress of the past 5 years has established a path that must be followed. The public sector move away from fee-for-service has combined with emerging technology platforms to create a new age where physicians and insurers can judge, in real time, how well care is working.
“We’re now in a feedback loop where we can say – ‘When we’ve built a care system like this or when we pay this way, we are actually seeing improved outcomes’ – and change doesn’t take as long,” Dr. DeSalvo said.
Dr. Conway, whose working title for his speech is “Health care System Transformation,” said hospitalists should be encouraged by how well the field has already adapted to the proliferation of accountable care organizations (ACOs), value-based purchasing (VBP), alternative payment models (APM), and the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. He noted that, as innovations lead to better and more coordinated patient care, hospitalists, patients, and hospitals would all benefit.
“I want to leave people with the idea that value-based payment innovation and delivery system reform will continue to be critical aspects of improving our health system,” he said. “I also want hospitalists to continue to stay engaged with these new payment models, help lead them, and provide better patient care as a part of them.”
Disappointment in article on NP, PA roles in HM groups
Editor’s note: The following “Letter to the Editor” was first emailed to the Society of Hospital Medicine, its board president, and John Nelson, MD, MHM, the author of the article, “Hospitalist Roles for NPs and PAs,” which published in the January 2017 issue. All parties agreed to publish the email exchange in The Hospitalist.
Sent: Sunday, February 12, 2017 9:59 AM
Subject: Offensive article on hospitalist roles for NPs, PAs
All,
I have been a hospitalist NP (nurse practitioner) for a decade and found the article in the January issue of The Hospitalist, Volume 21, Number 1, on the Hospitalist Roles for NPs and PAs, offensive and uninformed, with an intolerable amount of personal opinion not backed by research.
I am disappointed that The Hospitalist would publish such a low-class article. Your [magazine] promotes membership to all APPs (advanced practice providers), yet you publish articles that show a study with a positive finding yet allow and highlight an incredibly negative and offensive snippet. The highlighted box states that “Any group that thinks this study is evidence that adding more APPs and having them manage a high number of patients relatively independently will go well in any setting is MISTAKEN ... But it does offer a STORY of one place where, with careful planning and execution, it went OK.”
I can only say that the physicians, APPs, and hospital group who did this study would likely also be offended for taking their study and turning it into a “story.”
EDUCATE yourselves. There are numerous studies out there showing care by APP’s is cost effective, efficient, and with excellent care outcomes. There is a national group, APPex (Advanced Practice Provider Executives), that can give you all the studies you would want showing this information. Or contact the national NP or PA groups.
I am a working hospitalist NP and appreciate my physician colleagues and have their respect. This “John” person obviously doesn’t respect APPs and to publish him is just disheartening.
This publication could have and should have done better. You have one APP on your editorial advisory board – it appears you need more.
Marci Harris, MSN, FNP, ACNP
Acute Care Nurse Practitioner
Hospitalist/Internal Medicine
McKee Medical Center, Loveland, Colo.
Dr. Nelson responds:
Thanks for your message, Marci. It seems clear you’ve thought a lot about NPs and PAs in hospitalist practices and have arrived at conclusions that differ from what I wrote. Your voice and views are welcome.
I certainly didn’t intend to offend anyone, including those who might see all of this very differently from me.
As I mention in the first paragraph, I’m very supportive of NPs and PAs in hospitalist practices. And I wanted to write about this particular study precisely because it provides data that is very supportive of their contributions.
The point I was trying to make in the column is that there is value in careful planning around roles and who does what. A sports team could recruit the most talented players but still won’t perform well if they don’t develop and execute a good plan around who does what and how they work together. Simply having talented people on the team isn’t enough. I think the same is true of hospitalist teams.
The hospitalist group in the study has an impressively detailed plan for new provider (APC and MD alike) orientation and has a lot of operating processes that help ensure the PAs and MDs work effectively together. My experience is that many hospitalists groups have never developed such a plan.
John Nelson, MD, MHM
Partner, Nelson Flores Hospital Medicine Consultants, Bellevue, Wash.
Editor’s note: The following “Letter to the Editor” was first emailed to the Society of Hospital Medicine, its board president, and John Nelson, MD, MHM, the author of the article, “Hospitalist Roles for NPs and PAs,” which published in the January 2017 issue. All parties agreed to publish the email exchange in The Hospitalist.
Sent: Sunday, February 12, 2017 9:59 AM
Subject: Offensive article on hospitalist roles for NPs, PAs
All,
I have been a hospitalist NP (nurse practitioner) for a decade and found the article in the January issue of The Hospitalist, Volume 21, Number 1, on the Hospitalist Roles for NPs and PAs, offensive and uninformed, with an intolerable amount of personal opinion not backed by research.
I am disappointed that The Hospitalist would publish such a low-class article. Your [magazine] promotes membership to all APPs (advanced practice providers), yet you publish articles that show a study with a positive finding yet allow and highlight an incredibly negative and offensive snippet. The highlighted box states that “Any group that thinks this study is evidence that adding more APPs and having them manage a high number of patients relatively independently will go well in any setting is MISTAKEN ... But it does offer a STORY of one place where, with careful planning and execution, it went OK.”
I can only say that the physicians, APPs, and hospital group who did this study would likely also be offended for taking their study and turning it into a “story.”
EDUCATE yourselves. There are numerous studies out there showing care by APP’s is cost effective, efficient, and with excellent care outcomes. There is a national group, APPex (Advanced Practice Provider Executives), that can give you all the studies you would want showing this information. Or contact the national NP or PA groups.
I am a working hospitalist NP and appreciate my physician colleagues and have their respect. This “John” person obviously doesn’t respect APPs and to publish him is just disheartening.
This publication could have and should have done better. You have one APP on your editorial advisory board – it appears you need more.
Marci Harris, MSN, FNP, ACNP
Acute Care Nurse Practitioner
Hospitalist/Internal Medicine
McKee Medical Center, Loveland, Colo.
Dr. Nelson responds:
Thanks for your message, Marci. It seems clear you’ve thought a lot about NPs and PAs in hospitalist practices and have arrived at conclusions that differ from what I wrote. Your voice and views are welcome.
I certainly didn’t intend to offend anyone, including those who might see all of this very differently from me.
As I mention in the first paragraph, I’m very supportive of NPs and PAs in hospitalist practices. And I wanted to write about this particular study precisely because it provides data that is very supportive of their contributions.
The point I was trying to make in the column is that there is value in careful planning around roles and who does what. A sports team could recruit the most talented players but still won’t perform well if they don’t develop and execute a good plan around who does what and how they work together. Simply having talented people on the team isn’t enough. I think the same is true of hospitalist teams.
The hospitalist group in the study has an impressively detailed plan for new provider (APC and MD alike) orientation and has a lot of operating processes that help ensure the PAs and MDs work effectively together. My experience is that many hospitalists groups have never developed such a plan.
John Nelson, MD, MHM
Partner, Nelson Flores Hospital Medicine Consultants, Bellevue, Wash.
Editor’s note: The following “Letter to the Editor” was first emailed to the Society of Hospital Medicine, its board president, and John Nelson, MD, MHM, the author of the article, “Hospitalist Roles for NPs and PAs,” which published in the January 2017 issue. All parties agreed to publish the email exchange in The Hospitalist.
Sent: Sunday, February 12, 2017 9:59 AM
Subject: Offensive article on hospitalist roles for NPs, PAs
All,
I have been a hospitalist NP (nurse practitioner) for a decade and found the article in the January issue of The Hospitalist, Volume 21, Number 1, on the Hospitalist Roles for NPs and PAs, offensive and uninformed, with an intolerable amount of personal opinion not backed by research.
I am disappointed that The Hospitalist would publish such a low-class article. Your [magazine] promotes membership to all APPs (advanced practice providers), yet you publish articles that show a study with a positive finding yet allow and highlight an incredibly negative and offensive snippet. The highlighted box states that “Any group that thinks this study is evidence that adding more APPs and having them manage a high number of patients relatively independently will go well in any setting is MISTAKEN ... But it does offer a STORY of one place where, with careful planning and execution, it went OK.”
I can only say that the physicians, APPs, and hospital group who did this study would likely also be offended for taking their study and turning it into a “story.”
EDUCATE yourselves. There are numerous studies out there showing care by APP’s is cost effective, efficient, and with excellent care outcomes. There is a national group, APPex (Advanced Practice Provider Executives), that can give you all the studies you would want showing this information. Or contact the national NP or PA groups.
I am a working hospitalist NP and appreciate my physician colleagues and have their respect. This “John” person obviously doesn’t respect APPs and to publish him is just disheartening.
This publication could have and should have done better. You have one APP on your editorial advisory board – it appears you need more.
Marci Harris, MSN, FNP, ACNP
Acute Care Nurse Practitioner
Hospitalist/Internal Medicine
McKee Medical Center, Loveland, Colo.
Dr. Nelson responds:
Thanks for your message, Marci. It seems clear you’ve thought a lot about NPs and PAs in hospitalist practices and have arrived at conclusions that differ from what I wrote. Your voice and views are welcome.
I certainly didn’t intend to offend anyone, including those who might see all of this very differently from me.
As I mention in the first paragraph, I’m very supportive of NPs and PAs in hospitalist practices. And I wanted to write about this particular study precisely because it provides data that is very supportive of their contributions.
The point I was trying to make in the column is that there is value in careful planning around roles and who does what. A sports team could recruit the most talented players but still won’t perform well if they don’t develop and execute a good plan around who does what and how they work together. Simply having talented people on the team isn’t enough. I think the same is true of hospitalist teams.
The hospitalist group in the study has an impressively detailed plan for new provider (APC and MD alike) orientation and has a lot of operating processes that help ensure the PAs and MDs work effectively together. My experience is that many hospitalists groups have never developed such a plan.
John Nelson, MD, MHM
Partner, Nelson Flores Hospital Medicine Consultants, Bellevue, Wash.
Create hospitalist-patient partnerships for safety and quality
Hospitalists can help enlist patients in the movement toward improved patient safety, and they can begin simply by sharing their notes.
OpenNotes offers a new platform to do that, according to a BMJ Quality & Safety article, “A patient feedback reporting tool for OpenNotes: implications for patient-clinician safety and quality partnerships.”1
In their study, the researchers invited 6,225 patients to read clinicians’ notes and, through a patient portal, provide feedback. Forty-four percent of patients read the notes; nearly all (96%) respondents reported understanding the notes; 1 in 12 submitted feedback.
“Patients can [and did] find documentation errors in their notes and were willing to report them without any apparent negative effect on the patient-clinician relationship,” Dr. Bell says. “The majority of patients also wanted to share positive feedback with their providers. Sharing notes can also facilitate information transfer across care settings.”
Investigators also reported on feedback from patients that hearing the notes helped them to remember next steps.
“Reading discharge summaries and visit notes from follow-up visits after a hospitalization may prove particularly important,” Dr. Bell says. “Providing patients with access to their notes may help them to adhere to the care plan, better remember recommended follow up tests or visits, and potentially stem preventable readmissions.”
What hospitalists can do now, Dr. Bell adds, is:
- Share their notes with patients and families (by printing the discharge summaries if they are not available on the portal and/or sharing notes from post-discharge follow-up visits).
- Emphasize for patients and families the important role they play as safety partners.
- Ask patients who receive care in other healthcare centers if they have OpenNotes, which can help hospitalists obtain medical records quickly and efficiently.
- Encourage patients to sign up for the patient portal and ask for their notes, for ambulatory visits to begin with and for in-patient notes when they become available.
Suzanne Bopp is a freelance medical writer in New York City.
Reference
1. Bell SK, Gerard M, Fossa A, et al. A patient feedback reporting tool for OpenNotes: implications for patient-clinician safety and quality partnerships [published online ahead of print, Dec. 13, 2016]. BMJ Qual Saf. doi: 10.1136/bmjqs-2016-006020.
Hospitalists can help enlist patients in the movement toward improved patient safety, and they can begin simply by sharing their notes.
OpenNotes offers a new platform to do that, according to a BMJ Quality & Safety article, “A patient feedback reporting tool for OpenNotes: implications for patient-clinician safety and quality partnerships.”1
In their study, the researchers invited 6,225 patients to read clinicians’ notes and, through a patient portal, provide feedback. Forty-four percent of patients read the notes; nearly all (96%) respondents reported understanding the notes; 1 in 12 submitted feedback.
“Patients can [and did] find documentation errors in their notes and were willing to report them without any apparent negative effect on the patient-clinician relationship,” Dr. Bell says. “The majority of patients also wanted to share positive feedback with their providers. Sharing notes can also facilitate information transfer across care settings.”
Investigators also reported on feedback from patients that hearing the notes helped them to remember next steps.
“Reading discharge summaries and visit notes from follow-up visits after a hospitalization may prove particularly important,” Dr. Bell says. “Providing patients with access to their notes may help them to adhere to the care plan, better remember recommended follow up tests or visits, and potentially stem preventable readmissions.”
What hospitalists can do now, Dr. Bell adds, is:
- Share their notes with patients and families (by printing the discharge summaries if they are not available on the portal and/or sharing notes from post-discharge follow-up visits).
- Emphasize for patients and families the important role they play as safety partners.
- Ask patients who receive care in other healthcare centers if they have OpenNotes, which can help hospitalists obtain medical records quickly and efficiently.
- Encourage patients to sign up for the patient portal and ask for their notes, for ambulatory visits to begin with and for in-patient notes when they become available.
Suzanne Bopp is a freelance medical writer in New York City.
Reference
1. Bell SK, Gerard M, Fossa A, et al. A patient feedback reporting tool for OpenNotes: implications for patient-clinician safety and quality partnerships [published online ahead of print, Dec. 13, 2016]. BMJ Qual Saf. doi: 10.1136/bmjqs-2016-006020.
Hospitalists can help enlist patients in the movement toward improved patient safety, and they can begin simply by sharing their notes.
OpenNotes offers a new platform to do that, according to a BMJ Quality & Safety article, “A patient feedback reporting tool for OpenNotes: implications for patient-clinician safety and quality partnerships.”1
In their study, the researchers invited 6,225 patients to read clinicians’ notes and, through a patient portal, provide feedback. Forty-four percent of patients read the notes; nearly all (96%) respondents reported understanding the notes; 1 in 12 submitted feedback.
“Patients can [and did] find documentation errors in their notes and were willing to report them without any apparent negative effect on the patient-clinician relationship,” Dr. Bell says. “The majority of patients also wanted to share positive feedback with their providers. Sharing notes can also facilitate information transfer across care settings.”
Investigators also reported on feedback from patients that hearing the notes helped them to remember next steps.
“Reading discharge summaries and visit notes from follow-up visits after a hospitalization may prove particularly important,” Dr. Bell says. “Providing patients with access to their notes may help them to adhere to the care plan, better remember recommended follow up tests or visits, and potentially stem preventable readmissions.”
What hospitalists can do now, Dr. Bell adds, is:
- Share their notes with patients and families (by printing the discharge summaries if they are not available on the portal and/or sharing notes from post-discharge follow-up visits).
- Emphasize for patients and families the important role they play as safety partners.
- Ask patients who receive care in other healthcare centers if they have OpenNotes, which can help hospitalists obtain medical records quickly and efficiently.
- Encourage patients to sign up for the patient portal and ask for their notes, for ambulatory visits to begin with and for in-patient notes when they become available.
Suzanne Bopp is a freelance medical writer in New York City.
Reference
1. Bell SK, Gerard M, Fossa A, et al. A patient feedback reporting tool for OpenNotes: implications for patient-clinician safety and quality partnerships [published online ahead of print, Dec. 13, 2016]. BMJ Qual Saf. doi: 10.1136/bmjqs-2016-006020.
Assessment of goals of care in nursing home reduces hospitalization for patients with dementia
CLINICAL QUESTION: For patients with advanced dementia, does a goals-of-care intervention improve communication and care outcomes?
BACKGROUND: Patients with advanced dementia are frequently admitted from nursing homes for acute conditions. Prior research demonstrates deficits in documentation of advanced directives.
STUDY DESIGN: Single-blind cluster randomized trial.
SETTING: Twenty-two nursing homes in North Carolina.
BOTTOM LINE: Goals of care discussions for patients with advanced dementia appears to reduce hospitalizations.
CITATIONS: Hanson LC, Zimmerman S, Song MK, et al. Effect of the goals of care intervention for advanced dementia: a randomized clinical trial. JAMA Intern Med. 2017 Jan;177:24-31.
Dr. Cumbler is the associate chief of hospital medicine, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
CLINICAL QUESTION: For patients with advanced dementia, does a goals-of-care intervention improve communication and care outcomes?
BACKGROUND: Patients with advanced dementia are frequently admitted from nursing homes for acute conditions. Prior research demonstrates deficits in documentation of advanced directives.
STUDY DESIGN: Single-blind cluster randomized trial.
SETTING: Twenty-two nursing homes in North Carolina.
BOTTOM LINE: Goals of care discussions for patients with advanced dementia appears to reduce hospitalizations.
CITATIONS: Hanson LC, Zimmerman S, Song MK, et al. Effect of the goals of care intervention for advanced dementia: a randomized clinical trial. JAMA Intern Med. 2017 Jan;177:24-31.
Dr. Cumbler is the associate chief of hospital medicine, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.
CLINICAL QUESTION: For patients with advanced dementia, does a goals-of-care intervention improve communication and care outcomes?
BACKGROUND: Patients with advanced dementia are frequently admitted from nursing homes for acute conditions. Prior research demonstrates deficits in documentation of advanced directives.
STUDY DESIGN: Single-blind cluster randomized trial.
SETTING: Twenty-two nursing homes in North Carolina.
BOTTOM LINE: Goals of care discussions for patients with advanced dementia appears to reduce hospitalizations.
CITATIONS: Hanson LC, Zimmerman S, Song MK, et al. Effect of the goals of care intervention for advanced dementia: a randomized clinical trial. JAMA Intern Med. 2017 Jan;177:24-31.
Dr. Cumbler is the associate chief of hospital medicine, Division of Hospital Medicine, University of Colorado School of Medicine, Aurora.