The Hospitalist

Clinical Question: Can a collaborative quality improvement project improve the quality and efficiency of pediatric hospital discharges?

Background: Transitions of care, including at the time of hospital discharge, are a potential source of risk and can be associated with adverse events including medication errors and preventable readmissions. Some studies have shown that 10–20% of patients had an adverse event after discharge, and half of those were preventable; one adult study found nearly half of the discharged patients had at least one medication error.1,2 Although multiple projects to improve the discharge process have been published in adult literature, few have focused on the pediatric population. In this study, the Children’s Hospital Association (CHA) formed a pediatric quality improvement collaborative across multiple facilities to examine whether shared improvement strategies would affect failures of discharge-related care, parent-reported readiness for discharge, and readmission rates.

Study Design: Multicenter quality improvement collaborative.

Setting: 11 freestanding tertiary-care children’s hospitals in the United States.

Synopsis: Each of the 11 participating sites chose a specific target population, such as patients with sickle cell disease, asthma, or all discharged pediatric patients. Populations were selected at the discretion of the sites. A multidisciplinary expert advisory panel reviewed literature and developed a change package that included being proactive about discharge planning during hospitalization; improving throughput; arranging post-discharge treatment and support; and communicating post-discharge plan with patients, families, and providers. Each site selected elements of the change package to implement based on individual needs and preferences and incorporated via plan-do-study-act cycles during three action periods. Elements that were implemented by most or all sites included family education on diagnosis and discharge plans, use of discharge checklists, improvement of written discharge instructions, post-discharge follow-up phone calls to reinforce discharge instructions, and identifying and obtaining medications. Virtual learning conferences and monthly Web conferences were held for participants in the collaborative, and experienced improvement coaches guided teams through implementation.

The primary aim of the study was to reduce discharge-related care failures by 50% in 12 months. Failures were measured by phone calls to families two to seven days following discharge, and if any problem related to discharge occurred, the discharge was considered a failure (all-or-none measure). Components of this measure included understanding the diagnosis, receiving discharge instructions and education, complying with instructions, receiving necessary equipment, planning for follow-up pending tests, receiving help with appointments, and not requiring a related unplanned medical visit. Other measures evaluated in this study included patient/family readiness for discharge and unplanned readmission rates (72 hours and 30 days).

Overall, the rate of failures of discharge care was 34% at baseline, which decreased to 21% at the end of the collaborative, for a reduction of 40%. Some individual hospitals exceeded this mark as well. Among the hospitals reporting data on family readiness for discharge, there was a statistically significant improvement, with 85% of families at baseline rating readiness in the highest category and 91% in the last quarter of the study. There was no improvement in rates of unplanned readmission, with 72-hour readmission rates steady across the project (0.7% at onset, 1.1% at end of study; P = 0.29) and slight worsening of the 30-day rate (4.5% to 6.3%; P = 0.05).

Potential explanations for the findings related to readmission rates include seasonal variability in readmissions as well as high variability in patients included in the study. For example, one site focused on patients with sickle cell disease, another on patients with asthma, and others included all diagnoses. Overall, unplanned readmission rates were low (around 1% for 72-hour, 5% for 30-day), which is consistent with other pediatric studies.

Bottom Line: In this study, institutions using a collaborative approach improved the quality of inpatient discharges by using an intervention bundle in pediatric hospital settings. There was no improvement noted in readmission rates, although these rates were low.

Citation: Wu S, Tyler A, Logsdon T, et al. A quality improvement collaborative to improve the discharge process for hospitalized children. Pediatrics. 2016;138(2). pii:e20143604.

References:

1. Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003;18(8):646-651.
2. Forster AJ, Clark HD, Menard A, et al. Adverse events among medical patients after discharge from hospital. CMAJ. 2004;170(3):345-349.

Clinical Question: Can a collaborative quality improvement project improve the quality and efficiency of pediatric hospital discharges?

Background: Transitions of care, including at the time of hospital discharge, are a potential source of risk and can be associated with adverse events including medication errors and preventable readmissions. Some studies have shown that 10–20% of patients had an adverse event after discharge, and half of those were preventable; one adult study found nearly half of the discharged patients had at least one medication error.1,2 Although multiple projects to improve the discharge process have been published in adult literature, few have focused on the pediatric population. In this study, the Children’s Hospital Association (CHA) formed a pediatric quality improvement collaborative across multiple facilities to examine whether shared improvement strategies would affect failures of discharge-related care, parent-reported readiness for discharge, and readmission rates.

Study Design: Multicenter quality improvement collaborative.

Setting: 11 freestanding tertiary-care children’s hospitals in the United States.

Synopsis: Each of the 11 participating sites chose a specific target population, such as patients with sickle cell disease, asthma, or all discharged pediatric patients. Populations were selected at the discretion of the sites. A multidisciplinary expert advisory panel reviewed literature and developed a change package that included being proactive about discharge planning during hospitalization; improving throughput; arranging post-discharge treatment and support; and communicating post-discharge plan with patients, families, and providers. Each site selected elements of the change package to implement based on individual needs and preferences and incorporated via plan-do-study-act cycles during three action periods. Elements that were implemented by most or all sites included family education on diagnosis and discharge plans, use of discharge checklists, improvement of written discharge instructions, post-discharge follow-up phone calls to reinforce discharge instructions, and identifying and obtaining medications. Virtual learning conferences and monthly Web conferences were held for participants in the collaborative, and experienced improvement coaches guided teams through implementation.

The primary aim of the study was to reduce discharge-related care failures by 50% in 12 months. Failures were measured by phone calls to families two to seven days following discharge, and if any problem related to discharge occurred, the discharge was considered a failure (all-or-none measure). Components of this measure included understanding the diagnosis, receiving discharge instructions and education, complying with instructions, receiving necessary equipment, planning for follow-up pending tests, receiving help with appointments, and not requiring a related unplanned medical visit. Other measures evaluated in this study included patient/family readiness for discharge and unplanned readmission rates (72 hours and 30 days).

Overall, the rate of failures of discharge care was 34% at baseline, which decreased to 21% at the end of the collaborative, for a reduction of 40%. Some individual hospitals exceeded this mark as well. Among the hospitals reporting data on family readiness for discharge, there was a statistically significant improvement, with 85% of families at baseline rating readiness in the highest category and 91% in the last quarter of the study. There was no improvement in rates of unplanned readmission, with 72-hour readmission rates steady across the project (0.7% at onset, 1.1% at end of study; P = 0.29) and slight worsening of the 30-day rate (4.5% to 6.3%; P = 0.05).

Potential explanations for the findings related to readmission rates include seasonal variability in readmissions as well as high variability in patients included in the study. For example, one site focused on patients with sickle cell disease, another on patients with asthma, and others included all diagnoses. Overall, unplanned readmission rates were low (around 1% for 72-hour, 5% for 30-day), which is consistent with other pediatric studies.

Bottom Line: In this study, institutions using a collaborative approach improved the quality of inpatient discharges by using an intervention bundle in pediatric hospital settings. There was no improvement noted in readmission rates, although these rates were low.

Citation: Wu S, Tyler A, Logsdon T, et al. A quality improvement collaborative to improve the discharge process for hospitalized children. Pediatrics. 2016;138(2). pii:e20143604.

References:

1. Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003;18(8):646-651.
2. Forster AJ, Clark HD, Menard A, et al. Adverse events among medical patients after discharge from hospital. CMAJ. 2004;170(3):345-349.

Clinical Question: Can a collaborative quality improvement project improve the quality and efficiency of pediatric hospital discharges?

Background: Transitions of care, including at the time of hospital discharge, are a potential source of risk and can be associated with adverse events including medication errors and preventable readmissions. Some studies have shown that 10–20% of patients had an adverse event after discharge, and half of those were preventable; one adult study found nearly half of the discharged patients had at least one medication error.1,2 Although multiple projects to improve the discharge process have been published in adult literature, few have focused on the pediatric population. In this study, the Children’s Hospital Association (CHA) formed a pediatric quality improvement collaborative across multiple facilities to examine whether shared improvement strategies would affect failures of discharge-related care, parent-reported readiness for discharge, and readmission rates.

Study Design: Multicenter quality improvement collaborative.

Setting: 11 freestanding tertiary-care children’s hospitals in the United States.

Synopsis: Each of the 11 participating sites chose a specific target population, such as patients with sickle cell disease, asthma, or all discharged pediatric patients. Populations were selected at the discretion of the sites. A multidisciplinary expert advisory panel reviewed literature and developed a change package that included being proactive about discharge planning during hospitalization; improving throughput; arranging post-discharge treatment and support; and communicating post-discharge plan with patients, families, and providers. Each site selected elements of the change package to implement based on individual needs and preferences and incorporated via plan-do-study-act cycles during three action periods. Elements that were implemented by most or all sites included family education on diagnosis and discharge plans, use of discharge checklists, improvement of written discharge instructions, post-discharge follow-up phone calls to reinforce discharge instructions, and identifying and obtaining medications. Virtual learning conferences and monthly Web conferences were held for participants in the collaborative, and experienced improvement coaches guided teams through implementation.

The primary aim of the study was to reduce discharge-related care failures by 50% in 12 months. Failures were measured by phone calls to families two to seven days following discharge, and if any problem related to discharge occurred, the discharge was considered a failure (all-or-none measure). Components of this measure included understanding the diagnosis, receiving discharge instructions and education, complying with instructions, receiving necessary equipment, planning for follow-up pending tests, receiving help with appointments, and not requiring a related unplanned medical visit. Other measures evaluated in this study included patient/family readiness for discharge and unplanned readmission rates (72 hours and 30 days).

Overall, the rate of failures of discharge care was 34% at baseline, which decreased to 21% at the end of the collaborative, for a reduction of 40%. Some individual hospitals exceeded this mark as well. Among the hospitals reporting data on family readiness for discharge, there was a statistically significant improvement, with 85% of families at baseline rating readiness in the highest category and 91% in the last quarter of the study. There was no improvement in rates of unplanned readmission, with 72-hour readmission rates steady across the project (0.7% at onset, 1.1% at end of study; P = 0.29) and slight worsening of the 30-day rate (4.5% to 6.3%; P = 0.05).

Potential explanations for the findings related to readmission rates include seasonal variability in readmissions as well as high variability in patients included in the study. For example, one site focused on patients with sickle cell disease, another on patients with asthma, and others included all diagnoses. Overall, unplanned readmission rates were low (around 1% for 72-hour, 5% for 30-day), which is consistent with other pediatric studies.

Bottom Line: In this study, institutions using a collaborative approach improved the quality of inpatient discharges by using an intervention bundle in pediatric hospital settings. There was no improvement noted in readmission rates, although these rates were low.

Citation: Wu S, Tyler A, Logsdon T, et al. A quality improvement collaborative to improve the discharge process for hospitalized children. Pediatrics. 2016;138(2). pii:e20143604.

References:

1. Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003;18(8):646-651.
2. Forster AJ, Clark HD, Menard A, et al. Adverse events among medical patients after discharge from hospital. CMAJ. 2004;170(3):345-349.

Clinical Question: What is the performance of the Step-by-Step approach to evaluate febrile infants, and how does it compare to other existing criteria?

Background: Multiple studies have been performed to find the best set of criteria to identify febrile infants at low risk for bacterial infection in order to manage them in a less invasive manner. Common criteria used in the United States include Rochester, Philadelphia, and Boston criteria, initially published in the early 1990s. Since that time, management has evolved with the introduction of newer biomarkers such as C-reactive protein (CRP) and procalcitonin (PCT), and epidemiology has changed with immunizations and improvement in intrapartum antibiotic prophylaxis.

A new algorithm, Step-by-Step, has been developed by a group of European pediatric emergency physicians and has been shown retrospectively to accurately identify groups of patients according to risk of noninvasive or invasive bacterial infection (IBI). This algorithm uses a sequential approach, evaluating the general appearance, age of the patient, urinalysis, and then other lab findings including CRP, PCT, and absolute neutrophil count (ANC). In this study, the authors sought to validate this algorithm prospectively in a larger multicenter population.

Study Design: Multicenter prospective study.

Setting: 11 European pediatric emergency departments in Spain, Italy, and Switzerland.

Synopsis: This study included infants ≤90 days of age presenting to the pediatric emergency department (PED) between September 2012 and August 2014 with fever without source (defined as temperature ≥38°C measured by thermometer at home or in the PED, with normal physical examination and no respiratory signs or symptoms or diarrheal process). Labs obtained for each patient included urinalysis, urine culture (obtained by bladder catheterization or suprapubic aspiration), white blood cell count, PCT, CRP, and blood culture. Further testing and management were determined by the treating physician and management protocols of each center.

Exclusion criteria included:

• Clear source of fever by history or physical examination.
• No fever in the PED and fever assessed only subjectively by parents prior to presentation without the use of a thermometer.
• Absence of one or more of the above lab tests.
• Refusal of parents to participate.

The study included 2,185 infants. Of these, 504 were diagnosed with bacterial infection, including 87 (3.9%) with IBI (defined as positive blood or cerebrospinal fluid culture) and 417 (19.1%) with non-IBI (409 of which were urinary tract infections). Following the first part of the Step-by-Step approach, which uses general appearance (well-appearing versus ill-appearing), age (older or younger than 21 days), and leukocyturia, identified 79.3% of patients with IBI and 98.5% of non-IBI. Adding the next steps in the approach, with PCT, CRP, and ANC, identified 991 low-risk patients (45.3% of the studied population). In this low-risk group, seven patients were subsequently identified as having IBI (0.7% of this group). Using the Step-by-Step approach led to a negative predictive value (NPV) of 99.3 for identifying IBI, with a negative likelihood ratio (LR) of 0.17.

In evaluation of the seven low-risk patients with IBI, three of these were noted to present to the PED within one hour of onset of fever, and three more patients had fever first detected on arrival in the PED. This short duration of fever, and the lack of time for a rise in biomarkers, is likely why these patients were missed in the initial assessment.

When the Rochester criteria were used for this group of 2,185 patients, 949 patients were identified as low risk, with 1.6% of the low-risk patients found to have IBI, leading to an NPV of 98.3 and negative LR of 0.41. The authors chose to compare their approach to the Rochester criteria because the other commonly used approaches (Boston, Philadelphia) recommend lumbar puncture in all febrile infants while Rochester does not, and more recent literature suggests an individualized approach rather than recommending the test systematically.

Limitations included:

• Prevalence of bacterial infection was similar to other European publications but higher than in many studies in the United States, primarily due to an increased rate of UTI. (In this study, the authors used a definition of leukocyturia and culture with ≥10,000 cfu/mL.)
• Band count, although part of the Rochester criteria, was not available in some of the centers and not included in analysis. Inclusion of this lab study could have changed the performance of the Rochester criteria.
• The Step-by-Step approach was not compared to other existing criteria.

Bottom Line: In this study, the Step-by-Step approach was very accurate in identifying febrile infants at low risk for invasive bacterial infection, performing better than the Rochester criteria, and may be helpful in evaluation of infants with fever in the emergency department. A cautious approach is warranted for patients with very short fever duration, as they may be missed by ancillary test results.

Citation: Gomez B, Mintegi S, Bressan S, et al. Validation of the “step-by-step” approach in the management of young febrile infants. Pediatrics. 2016;138(2). pic:e20154381.

Carl Galloway, MD, is a hospitalist at Sanford Children’s Hospital in Sioux Falls, S.D.

Clinical Question: What is the performance of the Step-by-Step approach to evaluate febrile infants, and how does it compare to other existing criteria?

Background: Multiple studies have been performed to find the best set of criteria to identify febrile infants at low risk for bacterial infection in order to manage them in a less invasive manner. Common criteria used in the United States include Rochester, Philadelphia, and Boston criteria, initially published in the early 1990s. Since that time, management has evolved with the introduction of newer biomarkers such as C-reactive protein (CRP) and procalcitonin (PCT), and epidemiology has changed with immunizations and improvement in intrapartum antibiotic prophylaxis.

A new algorithm, Step-by-Step, has been developed by a group of European pediatric emergency physicians and has been shown retrospectively to accurately identify groups of patients according to risk of noninvasive or invasive bacterial infection (IBI). This algorithm uses a sequential approach, evaluating the general appearance, age of the patient, urinalysis, and then other lab findings including CRP, PCT, and absolute neutrophil count (ANC). In this study, the authors sought to validate this algorithm prospectively in a larger multicenter population.

Study Design: Multicenter prospective study.

Setting: 11 European pediatric emergency departments in Spain, Italy, and Switzerland.

Synopsis: This study included infants ≤90 days of age presenting to the pediatric emergency department (PED) between September 2012 and August 2014 with fever without source (defined as temperature ≥38°C measured by thermometer at home or in the PED, with normal physical examination and no respiratory signs or symptoms or diarrheal process). Labs obtained for each patient included urinalysis, urine culture (obtained by bladder catheterization or suprapubic aspiration), white blood cell count, PCT, CRP, and blood culture. Further testing and management were determined by the treating physician and management protocols of each center.

Exclusion criteria included:

• Clear source of fever by history or physical examination.
• No fever in the PED and fever assessed only subjectively by parents prior to presentation without the use of a thermometer.
• Absence of one or more of the above lab tests.
• Refusal of parents to participate.

The study included 2,185 infants. Of these, 504 were diagnosed with bacterial infection, including 87 (3.9%) with IBI (defined as positive blood or cerebrospinal fluid culture) and 417 (19.1%) with non-IBI (409 of which were urinary tract infections). Following the first part of the Step-by-Step approach, which uses general appearance (well-appearing versus ill-appearing), age (older or younger than 21 days), and leukocyturia, identified 79.3% of patients with IBI and 98.5% of non-IBI. Adding the next steps in the approach, with PCT, CRP, and ANC, identified 991 low-risk patients (45.3% of the studied population). In this low-risk group, seven patients were subsequently identified as having IBI (0.7% of this group). Using the Step-by-Step approach led to a negative predictive value (NPV) of 99.3 for identifying IBI, with a negative likelihood ratio (LR) of 0.17.

In evaluation of the seven low-risk patients with IBI, three of these were noted to present to the PED within one hour of onset of fever, and three more patients had fever first detected on arrival in the PED. This short duration of fever, and the lack of time for a rise in biomarkers, is likely why these patients were missed in the initial assessment.

When the Rochester criteria were used for this group of 2,185 patients, 949 patients were identified as low risk, with 1.6% of the low-risk patients found to have IBI, leading to an NPV of 98.3 and negative LR of 0.41. The authors chose to compare their approach to the Rochester criteria because the other commonly used approaches (Boston, Philadelphia) recommend lumbar puncture in all febrile infants while Rochester does not, and more recent literature suggests an individualized approach rather than recommending the test systematically.

Limitations included:

• Prevalence of bacterial infection was similar to other European publications but higher than in many studies in the United States, primarily due to an increased rate of UTI. (In this study, the authors used a definition of leukocyturia and culture with ≥10,000 cfu/mL.)
• Band count, although part of the Rochester criteria, was not available in some of the centers and not included in analysis. Inclusion of this lab study could have changed the performance of the Rochester criteria.
• The Step-by-Step approach was not compared to other existing criteria.

Bottom Line: In this study, the Step-by-Step approach was very accurate in identifying febrile infants at low risk for invasive bacterial infection, performing better than the Rochester criteria, and may be helpful in evaluation of infants with fever in the emergency department. A cautious approach is warranted for patients with very short fever duration, as they may be missed by ancillary test results.

Citation: Gomez B, Mintegi S, Bressan S, et al. Validation of the “step-by-step” approach in the management of young febrile infants. Pediatrics. 2016;138(2). pic:e20154381.

Carl Galloway, MD, is a hospitalist at Sanford Children’s Hospital in Sioux Falls, S.D.

Clinical Question: What is the performance of the Step-by-Step approach to evaluate febrile infants, and how does it compare to other existing criteria?

Background: Multiple studies have been performed to find the best set of criteria to identify febrile infants at low risk for bacterial infection in order to manage them in a less invasive manner. Common criteria used in the United States include Rochester, Philadelphia, and Boston criteria, initially published in the early 1990s. Since that time, management has evolved with the introduction of newer biomarkers such as C-reactive protein (CRP) and procalcitonin (PCT), and epidemiology has changed with immunizations and improvement in intrapartum antibiotic prophylaxis.

A new algorithm, Step-by-Step, has been developed by a group of European pediatric emergency physicians and has been shown retrospectively to accurately identify groups of patients according to risk of noninvasive or invasive bacterial infection (IBI). This algorithm uses a sequential approach, evaluating the general appearance, age of the patient, urinalysis, and then other lab findings including CRP, PCT, and absolute neutrophil count (ANC). In this study, the authors sought to validate this algorithm prospectively in a larger multicenter population.

Study Design: Multicenter prospective study.

Setting: 11 European pediatric emergency departments in Spain, Italy, and Switzerland.

Synopsis: This study included infants ≤90 days of age presenting to the pediatric emergency department (PED) between September 2012 and August 2014 with fever without source (defined as temperature ≥38°C measured by thermometer at home or in the PED, with normal physical examination and no respiratory signs or symptoms or diarrheal process). Labs obtained for each patient included urinalysis, urine culture (obtained by bladder catheterization or suprapubic aspiration), white blood cell count, PCT, CRP, and blood culture. Further testing and management were determined by the treating physician and management protocols of each center.

Exclusion criteria included:

• Clear source of fever by history or physical examination.
• No fever in the PED and fever assessed only subjectively by parents prior to presentation without the use of a thermometer.
• Absence of one or more of the above lab tests.
• Refusal of parents to participate.

The study included 2,185 infants. Of these, 504 were diagnosed with bacterial infection, including 87 (3.9%) with IBI (defined as positive blood or cerebrospinal fluid culture) and 417 (19.1%) with non-IBI (409 of which were urinary tract infections). Following the first part of the Step-by-Step approach, which uses general appearance (well-appearing versus ill-appearing), age (older or younger than 21 days), and leukocyturia, identified 79.3% of patients with IBI and 98.5% of non-IBI. Adding the next steps in the approach, with PCT, CRP, and ANC, identified 991 low-risk patients (45.3% of the studied population). In this low-risk group, seven patients were subsequently identified as having IBI (0.7% of this group). Using the Step-by-Step approach led to a negative predictive value (NPV) of 99.3 for identifying IBI, with a negative likelihood ratio (LR) of 0.17.

In evaluation of the seven low-risk patients with IBI, three of these were noted to present to the PED within one hour of onset of fever, and three more patients had fever first detected on arrival in the PED. This short duration of fever, and the lack of time for a rise in biomarkers, is likely why these patients were missed in the initial assessment.

When the Rochester criteria were used for this group of 2,185 patients, 949 patients were identified as low risk, with 1.6% of the low-risk patients found to have IBI, leading to an NPV of 98.3 and negative LR of 0.41. The authors chose to compare their approach to the Rochester criteria because the other commonly used approaches (Boston, Philadelphia) recommend lumbar puncture in all febrile infants while Rochester does not, and more recent literature suggests an individualized approach rather than recommending the test systematically.

Limitations included:

• Prevalence of bacterial infection was similar to other European publications but higher than in many studies in the United States, primarily due to an increased rate of UTI. (In this study, the authors used a definition of leukocyturia and culture with ≥10,000 cfu/mL.)
• Band count, although part of the Rochester criteria, was not available in some of the centers and not included in analysis. Inclusion of this lab study could have changed the performance of the Rochester criteria.
• The Step-by-Step approach was not compared to other existing criteria.

Bottom Line: In this study, the Step-by-Step approach was very accurate in identifying febrile infants at low risk for invasive bacterial infection, performing better than the Rochester criteria, and may be helpful in evaluation of infants with fever in the emergency department. A cautious approach is warranted for patients with very short fever duration, as they may be missed by ancillary test results.

Citation: Gomez B, Mintegi S, Bressan S, et al. Validation of the “step-by-step” approach in the management of young febrile infants. Pediatrics. 2016;138(2). pic:e20154381.

Carl Galloway, MD, is a hospitalist at Sanford Children’s Hospital in Sioux Falls, S.D.

The business of hospital medicine is an important factor in individual clinicians' careers and for the specialty as a whole. Dr. Jasen Gundersen of TeamHealth and James Levy of Indigo Health Partners talk about the importance of recognizing the personal, and the system-wide, impacts and opportunities of the business side of HM.

The business of hospital medicine is an important factor in individual clinicians' careers and for the specialty as a whole. Dr. Jasen Gundersen of TeamHealth and James Levy of Indigo Health Partners talk about the importance of recognizing the personal, and the system-wide, impacts and opportunities of the business side of HM.

The business of hospital medicine is an important factor in individual clinicians' careers and for the specialty as a whole. Dr. Jasen Gundersen of TeamHealth and James Levy of Indigo Health Partners talk about the importance of recognizing the personal, and the system-wide, impacts and opportunities of the business side of HM.

Congratulations to the recipients of the 2016 Pediatric Hospital Medicine Awards, who were recently recognized at the 2016 Pediatric Hospital Medicine meeting in Chicago. The awards are presented to pediatric hospitalists who make exemplary contributions to hospital medicine, quality improvement, and patient care.

The awards are presented in four categories:

Safety and Quality Improvement

Recipient: Kavita Parikh, MD, Children’s National Medical Center, Washington, D.C.

Dr. Parikh is a member of the Value in Inpatient Pediatrics Network and has worked with the group to improve the care of community-acquired pneumonia. The group has enrolled more than 50 hospitals around the country and one international site to standardize care so that all children hospitalized with pneumonia can receive the same high-quality care, including the use of narrow-spectrum antibiotics.

Educational Achievement and Innovation

Recipient: H. Barrett Fromme, MD, University of Chicago

Dr. Fromme is well known as a leader in pediatric medical education and was instrumental in establishing the Pediatric National Nighttime Curriculum, which includes approximately 75 percent of all residency programs across the U.S. She also led the Advancing Pediatric Educator Excellence Teaching Program for hospitalists, which helps develop their teaching skills. Dr. Fromme has also been named a Master Educator at the University of Chicago Academy of Distinguished Medical Educators.

Research Excellence

Recipient: Derek Williams, MD, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville

Dr. Williams is a pediatric hospitalist whose research activities have focused on respiratory infections in hospitalized children. He has received multiple grants and awards from the Centers for Disease Control and Prevention, National Institutes of Health, and Patient-Centered Outcomes Research Institute and has served as the lead investigator at his institution for the CDC-sponsored study entitled Etiology of Pneumonia in the Community (EPIC), which has generated several publications, including in The New England Journal of Medicine.

Lifetime Achievement

Recipient: Ken Roberts, MD, chairman emeritus, University of North Carolina, Chapel Hill

While he is now retired, Dr. Roberts has served as a mentor to many pediatric hospitalists throughout his storied career and has more than 200 publications, including one in Pediatrics called “A Hospitalist Movement? Where to?”

Congratulations to the recipients of the 2016 Pediatric Hospital Medicine Awards, who were recently recognized at the 2016 Pediatric Hospital Medicine meeting in Chicago. The awards are presented to pediatric hospitalists who make exemplary contributions to hospital medicine, quality improvement, and patient care.

The awards are presented in four categories:

Safety and Quality Improvement

Recipient: Kavita Parikh, MD, Children’s National Medical Center, Washington, D.C.

Dr. Parikh is a member of the Value in Inpatient Pediatrics Network and has worked with the group to improve the care of community-acquired pneumonia. The group has enrolled more than 50 hospitals around the country and one international site to standardize care so that all children hospitalized with pneumonia can receive the same high-quality care, including the use of narrow-spectrum antibiotics.

Educational Achievement and Innovation

Recipient: H. Barrett Fromme, MD, University of Chicago

Dr. Fromme is well known as a leader in pediatric medical education and was instrumental in establishing the Pediatric National Nighttime Curriculum, which includes approximately 75 percent of all residency programs across the U.S. She also led the Advancing Pediatric Educator Excellence Teaching Program for hospitalists, which helps develop their teaching skills. Dr. Fromme has also been named a Master Educator at the University of Chicago Academy of Distinguished Medical Educators.

Research Excellence

Recipient: Derek Williams, MD, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville

Dr. Williams is a pediatric hospitalist whose research activities have focused on respiratory infections in hospitalized children. He has received multiple grants and awards from the Centers for Disease Control and Prevention, National Institutes of Health, and Patient-Centered Outcomes Research Institute and has served as the lead investigator at his institution for the CDC-sponsored study entitled Etiology of Pneumonia in the Community (EPIC), which has generated several publications, including in The New England Journal of Medicine.

Lifetime Achievement

Recipient: Ken Roberts, MD, chairman emeritus, University of North Carolina, Chapel Hill

While he is now retired, Dr. Roberts has served as a mentor to many pediatric hospitalists throughout his storied career and has more than 200 publications, including one in Pediatrics called “A Hospitalist Movement? Where to?”

Congratulations to the recipients of the 2016 Pediatric Hospital Medicine Awards, who were recently recognized at the 2016 Pediatric Hospital Medicine meeting in Chicago. The awards are presented to pediatric hospitalists who make exemplary contributions to hospital medicine, quality improvement, and patient care.

The awards are presented in four categories:

Safety and Quality Improvement

Recipient: Kavita Parikh, MD, Children’s National Medical Center, Washington, D.C.

Dr. Parikh is a member of the Value in Inpatient Pediatrics Network and has worked with the group to improve the care of community-acquired pneumonia. The group has enrolled more than 50 hospitals around the country and one international site to standardize care so that all children hospitalized with pneumonia can receive the same high-quality care, including the use of narrow-spectrum antibiotics.

Educational Achievement and Innovation

Recipient: H. Barrett Fromme, MD, University of Chicago

Dr. Fromme is well known as a leader in pediatric medical education and was instrumental in establishing the Pediatric National Nighttime Curriculum, which includes approximately 75 percent of all residency programs across the U.S. She also led the Advancing Pediatric Educator Excellence Teaching Program for hospitalists, which helps develop their teaching skills. Dr. Fromme has also been named a Master Educator at the University of Chicago Academy of Distinguished Medical Educators.

Research Excellence

Recipient: Derek Williams, MD, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville

Dr. Williams is a pediatric hospitalist whose research activities have focused on respiratory infections in hospitalized children. He has received multiple grants and awards from the Centers for Disease Control and Prevention, National Institutes of Health, and Patient-Centered Outcomes Research Institute and has served as the lead investigator at his institution for the CDC-sponsored study entitled Etiology of Pneumonia in the Community (EPIC), which has generated several publications, including in The New England Journal of Medicine.

Lifetime Achievement

Recipient: Ken Roberts, MD, chairman emeritus, University of North Carolina, Chapel Hill

While he is now retired, Dr. Roberts has served as a mentor to many pediatric hospitalists throughout his storied career and has more than 200 publications, including one in Pediatrics called “A Hospitalist Movement? Where to?”

Clinical Question: Is diluted apple juice inferior to apple-flavored electrolyte oral rehydration solution in children with mild dehydration due to acute gastroenteritis?

Background: In the setting of acute gastroenteritis, teaching has classically been that the simple sugars in juice and sports drinks can worsen diarrhea and that they could cause hyponatremia since they are not isotonic. Due to this, the American Academy of Pediatrics recommends an electrolyte oral rehydration solution for children with dehydration and acute gastroenteritis. These solutions are more expensive and less palatable than juices. The authors sought to determine if diluted apple juice versus electrolyte oral rehydration fluid decreased the need for IV fluids, hospitalization, return visits, prolonged symptoms, or ongoing dehydration in mildly dehydrated children with acute gastroenteritis.

Study Design: Randomized single-blind non-inferiority prospective trial.

Setting: Single large tertiary-care pediatric emergency room.

Synopsis: Over five years, 3,668 patients were identified. Inclusion criteria were age >6 months or 8 kg of weight; Clinical Dehydration Scale score

Patients were challenged with small aliquots of these solutions and given ondansetron if they vomited. Upon discharge, they were sent home with 2 L of their solution. In the control arm, families were instructed to use this solution to make up for any ongoing losses. In the experimental arm, families were instructed to provide whatever fluids they would prefer. Follow-up was via phone, mail, and in-person reassessments. Patients were considered to have failed treatment if they required hospitalization, IV fluids, or a repeat unscheduled visit to a physician or experienced diarrhea lasting more than seven days or worsening dehydration on follow-up.

In the experimental arm, 16.7% of patients failed treatment (95% CI, 12.8%–21.2%) compared to 25% in the control arm (95% CI, 20.4%–30.1%; P < 0.001 for non-inferiority, P = .006 for superiority). The experimental arm also required IV fluids (2.5% versus 9%) significantly less often, though without a significantly decreased rate of hospitalization. These differences were present primarily in children >24 months old. No difference in the frequency of diarrheal stools was found, and no episodes of significant hyponatremia occurred.

Bottom Line: Giving children with mild dehydration due to acute gastroenteritis diluted apple juice and preferred fluids rather than the currently recommended electrolyte oral rehydration solution leads to decreased treatment failures and decreased need for IV fluids. There was no evidence of worsened diarrhea or significant hyponatremia.

Citation: Freedman SB, Willan AR, Boutis K, Schuh S. Effect of dilute apple juice and preferred fluids vs electrolyte maintenance solution on treatment failure among children with mild gastroenteritis: a randomized clinical trial. JAMA. 2016;315(18):1966-1974. doi:10.1001/jama.2016.5352.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

Clinical Question: Is diluted apple juice inferior to apple-flavored electrolyte oral rehydration solution in children with mild dehydration due to acute gastroenteritis?

Background: In the setting of acute gastroenteritis, teaching has classically been that the simple sugars in juice and sports drinks can worsen diarrhea and that they could cause hyponatremia since they are not isotonic. Due to this, the American Academy of Pediatrics recommends an electrolyte oral rehydration solution for children with dehydration and acute gastroenteritis. These solutions are more expensive and less palatable than juices. The authors sought to determine if diluted apple juice versus electrolyte oral rehydration fluid decreased the need for IV fluids, hospitalization, return visits, prolonged symptoms, or ongoing dehydration in mildly dehydrated children with acute gastroenteritis.

Study Design: Randomized single-blind non-inferiority prospective trial.

Setting: Single large tertiary-care pediatric emergency room.

Synopsis: Over five years, 3,668 patients were identified. Inclusion criteria were age >6 months or 8 kg of weight; Clinical Dehydration Scale score

Patients were challenged with small aliquots of these solutions and given ondansetron if they vomited. Upon discharge, they were sent home with 2 L of their solution. In the control arm, families were instructed to use this solution to make up for any ongoing losses. In the experimental arm, families were instructed to provide whatever fluids they would prefer. Follow-up was via phone, mail, and in-person reassessments. Patients were considered to have failed treatment if they required hospitalization, IV fluids, or a repeat unscheduled visit to a physician or experienced diarrhea lasting more than seven days or worsening dehydration on follow-up.

In the experimental arm, 16.7% of patients failed treatment (95% CI, 12.8%–21.2%) compared to 25% in the control arm (95% CI, 20.4%–30.1%; P < 0.001 for non-inferiority, P = .006 for superiority). The experimental arm also required IV fluids (2.5% versus 9%) significantly less often, though without a significantly decreased rate of hospitalization. These differences were present primarily in children >24 months old. No difference in the frequency of diarrheal stools was found, and no episodes of significant hyponatremia occurred.

Bottom Line: Giving children with mild dehydration due to acute gastroenteritis diluted apple juice and preferred fluids rather than the currently recommended electrolyte oral rehydration solution leads to decreased treatment failures and decreased need for IV fluids. There was no evidence of worsened diarrhea or significant hyponatremia.

Citation: Freedman SB, Willan AR, Boutis K, Schuh S. Effect of dilute apple juice and preferred fluids vs electrolyte maintenance solution on treatment failure among children with mild gastroenteritis: a randomized clinical trial. JAMA. 2016;315(18):1966-1974. doi:10.1001/jama.2016.5352.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

Clinical Question: Is diluted apple juice inferior to apple-flavored electrolyte oral rehydration solution in children with mild dehydration due to acute gastroenteritis?

Background: In the setting of acute gastroenteritis, teaching has classically been that the simple sugars in juice and sports drinks can worsen diarrhea and that they could cause hyponatremia since they are not isotonic. Due to this, the American Academy of Pediatrics recommends an electrolyte oral rehydration solution for children with dehydration and acute gastroenteritis. These solutions are more expensive and less palatable than juices. The authors sought to determine if diluted apple juice versus electrolyte oral rehydration fluid decreased the need for IV fluids, hospitalization, return visits, prolonged symptoms, or ongoing dehydration in mildly dehydrated children with acute gastroenteritis.

Study Design: Randomized single-blind non-inferiority prospective trial.

Setting: Single large tertiary-care pediatric emergency room.

Synopsis: Over five years, 3,668 patients were identified. Inclusion criteria were age >6 months or 8 kg of weight; Clinical Dehydration Scale score

Patients were challenged with small aliquots of these solutions and given ondansetron if they vomited. Upon discharge, they were sent home with 2 L of their solution. In the control arm, families were instructed to use this solution to make up for any ongoing losses. In the experimental arm, families were instructed to provide whatever fluids they would prefer. Follow-up was via phone, mail, and in-person reassessments. Patients were considered to have failed treatment if they required hospitalization, IV fluids, or a repeat unscheduled visit to a physician or experienced diarrhea lasting more than seven days or worsening dehydration on follow-up.

In the experimental arm, 16.7% of patients failed treatment (95% CI, 12.8%–21.2%) compared to 25% in the control arm (95% CI, 20.4%–30.1%; P < 0.001 for non-inferiority, P = .006 for superiority). The experimental arm also required IV fluids (2.5% versus 9%) significantly less often, though without a significantly decreased rate of hospitalization. These differences were present primarily in children >24 months old. No difference in the frequency of diarrheal stools was found, and no episodes of significant hyponatremia occurred.

Bottom Line: Giving children with mild dehydration due to acute gastroenteritis diluted apple juice and preferred fluids rather than the currently recommended electrolyte oral rehydration solution leads to decreased treatment failures and decreased need for IV fluids. There was no evidence of worsened diarrhea or significant hyponatremia.

Citation: Freedman SB, Willan AR, Boutis K, Schuh S. Effect of dilute apple juice and preferred fluids vs electrolyte maintenance solution on treatment failure among children with mild gastroenteritis: a randomized clinical trial. JAMA. 2016;315(18):1966-1974. doi:10.1001/jama.2016.5352.

Dr. Stubblefield is a pediatric hospitalist at Nemours/Alfred I. Dupont Hospital for Children in Wilmington, Del., and assistant professor of pediatrics at Thomas Jefferson Medical College in Philadelphia.

Decreasing antimicrobial resistance and improving the correct use of antimicrobials is a national priority. According to CDC estimates, at least 2 million illnesses and 23,000 deaths annually are caused by antibiotic-resistant bacteria in the United States alone.

“Antimicrobial resistance is a serious global healthcare issue,” says Kelly Podgorny, DNP, MS, CPHQ, RN, project director at The Joint Commission. “If you review the scientific literature, it will indicate that we’re in crisis mode right now because of this.”

That’s why The Joint Commission recently announced a new Medication Management (MM) standard for hospitals, critical-access hospitals, and nursing care centers. This standard addresses antimicrobial stewardship and becomes effective January 1, 2017.

The Joint Commission is one of many organizations implementing plans to support the national action plan on this issue developed by the White House and signed by President Barack Obama. The purpose of The Joint Commission’s antimicrobial stewardship standard is to improve quality and patient safety and also to support, through its accreditation process, imperatives and actions at a national level.

The Joint Commission’s standard includes medications beyond just antibiotics by addressing antimicrobial stewardship. Clifford Chen, MD and Steven Eagle, MD

“Most of the organizations are focusing on antibiotics,” Podgorny says. “We broadened our perspective. The World Health Organization states that antimicrobial resistance threatens the effective prevention and treatment of an ever-increasing range of infections caused by bacteria, which would be antibiotics, but also includes parasites, viruses, and fungi.”

She emphasizes that hospitals need to have an effective antimicrobial stewardship program supported by hospital leadership. In fact, in The Joint Commission’s standard, the first element of performance requires leadership to establish antimicrobial stewardship as an organizational priority.

For hospitalists, antimicrobial stewardship should be a major issue in their daily work lives.

“The CDC states that studies indicate that 30–50% percent of antibiotics, and we’re just talking about antibiotics here, prescribed in hospitals are unnecessary or inappropriate,” Podgorny says.

References

1. Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States, 2012.

   2. The Joint Commission. New Antimicrobial Stewardship Standard. Accessed September 25, 2016.

Quick Byte

Improving the Bundled Payment Model

Researchers took national Medicare fee-for-service claims for the period 2011–2012 and evaluated how 30- and 90-day episode-based spending related to patient satisfaction and surgical mortality. Results showed patients who had major surgery at high-quality hospitals cost Medicare less than patients at low-quality hospitals. Post-acute care accounted for 59.5% of the difference in 30-day episode spending. Researchers concluded that efforts to increase value with bundled payment should pay attention to improving the care at low-quality hospitals and reducing unnecessary post-acute care.

Reference

1. Tsai TC, Greaves F, Zheng J, Orav EJ, Zinner MJ, Jha AK. Better patient care at high-quality hospitals may save Medicare money and bolster episode-based payment models. Health Aff (Millwood). 2016;35(9):1681-1689.

Decreasing antimicrobial resistance and improving the correct use of antimicrobials is a national priority. According to CDC estimates, at least 2 million illnesses and 23,000 deaths annually are caused by antibiotic-resistant bacteria in the United States alone.

“Antimicrobial resistance is a serious global healthcare issue,” says Kelly Podgorny, DNP, MS, CPHQ, RN, project director at The Joint Commission. “If you review the scientific literature, it will indicate that we’re in crisis mode right now because of this.”

That’s why The Joint Commission recently announced a new Medication Management (MM) standard for hospitals, critical-access hospitals, and nursing care centers. This standard addresses antimicrobial stewardship and becomes effective January 1, 2017.

The Joint Commission is one of many organizations implementing plans to support the national action plan on this issue developed by the White House and signed by President Barack Obama. The purpose of The Joint Commission’s antimicrobial stewardship standard is to improve quality and patient safety and also to support, through its accreditation process, imperatives and actions at a national level.

The Joint Commission’s standard includes medications beyond just antibiotics by addressing antimicrobial stewardship. Clifford Chen, MD and Steven Eagle, MD

“Most of the organizations are focusing on antibiotics,” Podgorny says. “We broadened our perspective. The World Health Organization states that antimicrobial resistance threatens the effective prevention and treatment of an ever-increasing range of infections caused by bacteria, which would be antibiotics, but also includes parasites, viruses, and fungi.”

She emphasizes that hospitals need to have an effective antimicrobial stewardship program supported by hospital leadership. In fact, in The Joint Commission’s standard, the first element of performance requires leadership to establish antimicrobial stewardship as an organizational priority.

For hospitalists, antimicrobial stewardship should be a major issue in their daily work lives.

“The CDC states that studies indicate that 30–50% percent of antibiotics, and we’re just talking about antibiotics here, prescribed in hospitals are unnecessary or inappropriate,” Podgorny says.

References

1. Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States, 2012.

   2. The Joint Commission. New Antimicrobial Stewardship Standard. Accessed September 25, 2016.

Quick Byte

Improving the Bundled Payment Model

Researchers took national Medicare fee-for-service claims for the period 2011–2012 and evaluated how 30- and 90-day episode-based spending related to patient satisfaction and surgical mortality. Results showed patients who had major surgery at high-quality hospitals cost Medicare less than patients at low-quality hospitals. Post-acute care accounted for 59.5% of the difference in 30-day episode spending. Researchers concluded that efforts to increase value with bundled payment should pay attention to improving the care at low-quality hospitals and reducing unnecessary post-acute care.

Reference

1. Tsai TC, Greaves F, Zheng J, Orav EJ, Zinner MJ, Jha AK. Better patient care at high-quality hospitals may save Medicare money and bolster episode-based payment models. Health Aff (Millwood). 2016;35(9):1681-1689.

Decreasing antimicrobial resistance and improving the correct use of antimicrobials is a national priority. According to CDC estimates, at least 2 million illnesses and 23,000 deaths annually are caused by antibiotic-resistant bacteria in the United States alone.

“Antimicrobial resistance is a serious global healthcare issue,” says Kelly Podgorny, DNP, MS, CPHQ, RN, project director at The Joint Commission. “If you review the scientific literature, it will indicate that we’re in crisis mode right now because of this.”

That’s why The Joint Commission recently announced a new Medication Management (MM) standard for hospitals, critical-access hospitals, and nursing care centers. This standard addresses antimicrobial stewardship and becomes effective January 1, 2017.

The Joint Commission is one of many organizations implementing plans to support the national action plan on this issue developed by the White House and signed by President Barack Obama. The purpose of The Joint Commission’s antimicrobial stewardship standard is to improve quality and patient safety and also to support, through its accreditation process, imperatives and actions at a national level.

The Joint Commission’s standard includes medications beyond just antibiotics by addressing antimicrobial stewardship. Clifford Chen, MD and Steven Eagle, MD

“Most of the organizations are focusing on antibiotics,” Podgorny says. “We broadened our perspective. The World Health Organization states that antimicrobial resistance threatens the effective prevention and treatment of an ever-increasing range of infections caused by bacteria, which would be antibiotics, but also includes parasites, viruses, and fungi.”

She emphasizes that hospitals need to have an effective antimicrobial stewardship program supported by hospital leadership. In fact, in The Joint Commission’s standard, the first element of performance requires leadership to establish antimicrobial stewardship as an organizational priority.

For hospitalists, antimicrobial stewardship should be a major issue in their daily work lives.

“The CDC states that studies indicate that 30–50% percent of antibiotics, and we’re just talking about antibiotics here, prescribed in hospitals are unnecessary or inappropriate,” Podgorny says.

References

1. Centers for Disease Control and Prevention. Antibiotic Resistance Threats in the United States, 2012.

   2. The Joint Commission. New Antimicrobial Stewardship Standard. Accessed September 25, 2016.

Quick Byte

Improving the Bundled Payment Model

Researchers took national Medicare fee-for-service claims for the period 2011–2012 and evaluated how 30- and 90-day episode-based spending related to patient satisfaction and surgical mortality. Results showed patients who had major surgery at high-quality hospitals cost Medicare less than patients at low-quality hospitals. Post-acute care accounted for 59.5% of the difference in 30-day episode spending. Researchers concluded that efforts to increase value with bundled payment should pay attention to improving the care at low-quality hospitals and reducing unnecessary post-acute care.

Reference

1. Tsai TC, Greaves F, Zheng J, Orav EJ, Zinner MJ, Jha AK. Better patient care at high-quality hospitals may save Medicare money and bolster episode-based payment models. Health Aff (Millwood). 2016;35(9):1681-1689.

What started with a car dealership survey has become a near avalanche of surveys from my credit card, bank, airlines, hotels, and other businesses. Each starts by assuring me that it will take only a minute or two to complete the survey, but if I completed every survey sent my way, it would add up to a significant amount of time. So I’ve stopped responding to nearly all of them, not so much as a form of protest but as part of my overall time-management efforts.

I imagine many of our patients see surveys from hospitals and other healthcare providers similarly: just another one to add to the pile. Patients in their 80s and 90s—a significant portion of hospitalist patients—probably interact a lot less with companies that send satisfaction surveys and so might be more attentive to ones from healthcare organizations. But I suspect that a reasonable portion of older patients rely on a family member to complete them, and this person, often a son or daughter, probably does get a lot of similar surveys. Surely, survey fatigue is influencing the results at least a little.

Healthcare Surveys: HCAHPS

For all the surveying going on, I find it pretty difficult to use HCAHPS results to guide patient-satisfaction improvement efforts. Sure, I can see how individual doctors or different physician groups score compared to one another and try to model my behaviors after the high performers. That is a really valuable thing to do, but it doesn’t get to the granular level I’d like.

One would hope the three physician-specific HCAHPS questions would support drilling down to more actionable information. But every hospitalist group I’ve seen always has the same pattern, scoring from lowest to highest as follows:

• How often did doctors explain things in a way you could understand?
• How often did doctors listen carefully to you?
• How often did doctors treat you with courtesy and respect?

So I don’t think the difference in scores on these questions is very useful in guiding improvement efforts.

Looking beyond HCAHPS

For a few years, our hospitalist group added a very short survey to the brochure describing the practice. I still think that was good idea to ensure accurate attribution and more granular information, but it didn’t yield much value in practice because of a low response rate. Ultimately, we stopped using it because of our hospital risk manager’s concern any such survey could be construed as “coaching” patients in their HCAHPS responses, something the Centers for Medicare & Medicaid Services forbids.

Mark Rudolph, MD, vice president of physician development and patient experience at Sound Physicians, told me about their experience with their employed RNs using tablet computers to survey every patient the day following hospital admission (i.e., while patients were still in the hospital). It seems to me this could be a really valuable tool to provide very granular feedback at the outset of a patient stay when there is still time to address areas in which the patient is less satisfied. They found that for about 30% of patients, the survey uncovered something that could be fixed, such as providing another blanket, determining what time a test was likely to be done, etc. I bet for most patients the fact that a nurse cared enough to ask how things are going and try to remedy problems improved their HCAPHS scores.

Yet after some experience with this approach, Sound Physicians found that, for a number of reasons, this wasn’t as valuable as hoped. They now survey a smaller sample of patients and sometimes adjust the questions based on the known or suspected strengths and weaknesses of individual providers. For one doctor, for example, the survey might ask whether the doctor spent enough time with the patient; for another, it might ask if the doctor spoke clearly, etc.

Dr. Rudolph thinks having someone such as the lead hospitalist observe the doctor while on rounds might ultimately prove more valuable than administering a survey. It will be interesting to see how his group and others around the country evolve their approach to better understand each provider’s strengths and weaknesses and most effective ways to improve patient satisfaction.

How to Improve Patient Satisfaction?

In my April 2012 column, I wrote about several things for hospitalists to consider including in their patient-satisfaction improvement plan. And, of course, there are a lot of additional sources of ideas available just by searching the Internet.

I find it difficult to consistently implement a bundle of multiple different habits, such as always sitting or always rounding with the patient’s bedside nurse, etc. I acknowledge these are proven valuable strategies to improve scores, but I still find it hard to do them consistently.

For some of us, it might be better to pick one thing to focus on. And while I don’t have research data to prove it, I think the single most valuable thing to improve patient satisfaction with hospitalists is to phone patients after discharge. It isn’t as difficult as most assume, and it often leads patients (or the family member you reach) to thank you profusely for the call. I think hospitalists can really benefit from more expressions of gratitude from patients and families, and these calls often provide it.

I’ve learned a few lessons about making post-discharge calls that are detailed in my August 2012 column. TH

What started with a car dealership survey has become a near avalanche of surveys from my credit card, bank, airlines, hotels, and other businesses. Each starts by assuring me that it will take only a minute or two to complete the survey, but if I completed every survey sent my way, it would add up to a significant amount of time. So I’ve stopped responding to nearly all of them, not so much as a form of protest but as part of my overall time-management efforts.

I imagine many of our patients see surveys from hospitals and other healthcare providers similarly: just another one to add to the pile. Patients in their 80s and 90s—a significant portion of hospitalist patients—probably interact a lot less with companies that send satisfaction surveys and so might be more attentive to ones from healthcare organizations. But I suspect that a reasonable portion of older patients rely on a family member to complete them, and this person, often a son or daughter, probably does get a lot of similar surveys. Surely, survey fatigue is influencing the results at least a little.

Healthcare Surveys: HCAHPS

For all the surveying going on, I find it pretty difficult to use HCAHPS results to guide patient-satisfaction improvement efforts. Sure, I can see how individual doctors or different physician groups score compared to one another and try to model my behaviors after the high performers. That is a really valuable thing to do, but it doesn’t get to the granular level I’d like.

One would hope the three physician-specific HCAHPS questions would support drilling down to more actionable information. But every hospitalist group I’ve seen always has the same pattern, scoring from lowest to highest as follows:

• How often did doctors explain things in a way you could understand?
• How often did doctors listen carefully to you?
• How often did doctors treat you with courtesy and respect?

So I don’t think the difference in scores on these questions is very useful in guiding improvement efforts.

Looking beyond HCAHPS

For a few years, our hospitalist group added a very short survey to the brochure describing the practice. I still think that was good idea to ensure accurate attribution and more granular information, but it didn’t yield much value in practice because of a low response rate. Ultimately, we stopped using it because of our hospital risk manager’s concern any such survey could be construed as “coaching” patients in their HCAHPS responses, something the Centers for Medicare & Medicaid Services forbids.

Mark Rudolph, MD, vice president of physician development and patient experience at Sound Physicians, told me about their experience with their employed RNs using tablet computers to survey every patient the day following hospital admission (i.e., while patients were still in the hospital). It seems to me this could be a really valuable tool to provide very granular feedback at the outset of a patient stay when there is still time to address areas in which the patient is less satisfied. They found that for about 30% of patients, the survey uncovered something that could be fixed, such as providing another blanket, determining what time a test was likely to be done, etc. I bet for most patients the fact that a nurse cared enough to ask how things are going and try to remedy problems improved their HCAPHS scores.

Yet after some experience with this approach, Sound Physicians found that, for a number of reasons, this wasn’t as valuable as hoped. They now survey a smaller sample of patients and sometimes adjust the questions based on the known or suspected strengths and weaknesses of individual providers. For one doctor, for example, the survey might ask whether the doctor spent enough time with the patient; for another, it might ask if the doctor spoke clearly, etc.

Dr. Rudolph thinks having someone such as the lead hospitalist observe the doctor while on rounds might ultimately prove more valuable than administering a survey. It will be interesting to see how his group and others around the country evolve their approach to better understand each provider’s strengths and weaknesses and most effective ways to improve patient satisfaction.

How to Improve Patient Satisfaction?

In my April 2012 column, I wrote about several things for hospitalists to consider including in their patient-satisfaction improvement plan. And, of course, there are a lot of additional sources of ideas available just by searching the Internet.

I find it difficult to consistently implement a bundle of multiple different habits, such as always sitting or always rounding with the patient’s bedside nurse, etc. I acknowledge these are proven valuable strategies to improve scores, but I still find it hard to do them consistently.

For some of us, it might be better to pick one thing to focus on. And while I don’t have research data to prove it, I think the single most valuable thing to improve patient satisfaction with hospitalists is to phone patients after discharge. It isn’t as difficult as most assume, and it often leads patients (or the family member you reach) to thank you profusely for the call. I think hospitalists can really benefit from more expressions of gratitude from patients and families, and these calls often provide it.

I’ve learned a few lessons about making post-discharge calls that are detailed in my August 2012 column. TH

What started with a car dealership survey has become a near avalanche of surveys from my credit card, bank, airlines, hotels, and other businesses. Each starts by assuring me that it will take only a minute or two to complete the survey, but if I completed every survey sent my way, it would add up to a significant amount of time. So I’ve stopped responding to nearly all of them, not so much as a form of protest but as part of my overall time-management efforts.

I imagine many of our patients see surveys from hospitals and other healthcare providers similarly: just another one to add to the pile. Patients in their 80s and 90s—a significant portion of hospitalist patients—probably interact a lot less with companies that send satisfaction surveys and so might be more attentive to ones from healthcare organizations. But I suspect that a reasonable portion of older patients rely on a family member to complete them, and this person, often a son or daughter, probably does get a lot of similar surveys. Surely, survey fatigue is influencing the results at least a little.

Healthcare Surveys: HCAHPS

For all the surveying going on, I find it pretty difficult to use HCAHPS results to guide patient-satisfaction improvement efforts. Sure, I can see how individual doctors or different physician groups score compared to one another and try to model my behaviors after the high performers. That is a really valuable thing to do, but it doesn’t get to the granular level I’d like.

One would hope the three physician-specific HCAHPS questions would support drilling down to more actionable information. But every hospitalist group I’ve seen always has the same pattern, scoring from lowest to highest as follows:

• How often did doctors explain things in a way you could understand?
• How often did doctors listen carefully to you?
• How often did doctors treat you with courtesy and respect?

So I don’t think the difference in scores on these questions is very useful in guiding improvement efforts.

Looking beyond HCAHPS

For a few years, our hospitalist group added a very short survey to the brochure describing the practice. I still think that was good idea to ensure accurate attribution and more granular information, but it didn’t yield much value in practice because of a low response rate. Ultimately, we stopped using it because of our hospital risk manager’s concern any such survey could be construed as “coaching” patients in their HCAHPS responses, something the Centers for Medicare & Medicaid Services forbids.

Mark Rudolph, MD, vice president of physician development and patient experience at Sound Physicians, told me about their experience with their employed RNs using tablet computers to survey every patient the day following hospital admission (i.e., while patients were still in the hospital). It seems to me this could be a really valuable tool to provide very granular feedback at the outset of a patient stay when there is still time to address areas in which the patient is less satisfied. They found that for about 30% of patients, the survey uncovered something that could be fixed, such as providing another blanket, determining what time a test was likely to be done, etc. I bet for most patients the fact that a nurse cared enough to ask how things are going and try to remedy problems improved their HCAPHS scores.

Yet after some experience with this approach, Sound Physicians found that, for a number of reasons, this wasn’t as valuable as hoped. They now survey a smaller sample of patients and sometimes adjust the questions based on the known or suspected strengths and weaknesses of individual providers. For one doctor, for example, the survey might ask whether the doctor spent enough time with the patient; for another, it might ask if the doctor spoke clearly, etc.

Dr. Rudolph thinks having someone such as the lead hospitalist observe the doctor while on rounds might ultimately prove more valuable than administering a survey. It will be interesting to see how his group and others around the country evolve their approach to better understand each provider’s strengths and weaknesses and most effective ways to improve patient satisfaction.

How to Improve Patient Satisfaction?

In my April 2012 column, I wrote about several things for hospitalists to consider including in their patient-satisfaction improvement plan. And, of course, there are a lot of additional sources of ideas available just by searching the Internet.

I find it difficult to consistently implement a bundle of multiple different habits, such as always sitting or always rounding with the patient’s bedside nurse, etc. I acknowledge these are proven valuable strategies to improve scores, but I still find it hard to do them consistently.

For some of us, it might be better to pick one thing to focus on. And while I don’t have research data to prove it, I think the single most valuable thing to improve patient satisfaction with hospitalists is to phone patients after discharge. It isn’t as difficult as most assume, and it often leads patients (or the family member you reach) to thank you profusely for the call. I think hospitalists can really benefit from more expressions of gratitude from patients and families, and these calls often provide it.

I’ve learned a few lessons about making post-discharge calls that are detailed in my August 2012 column. TH

This month, The Hospitalist spotlights G. Randy Smith Jr., MD, MS, SFHM, assistant professor in the Division of Hospital Medicine at the Northwestern University Feinberg School of Medicine and medical director of Unit 16 West at Northwestern Memorial Hospital in Chicago. Dr. Smith is an active member of SHM’s Practice Analysis Committee and a Leadership Academy veteran who has translated his learnings into more efficient rounding and patient-flow methodology.

Question: What inspired you to begin working in hospital medicine and later join SHM?

Answer: Interest in taking care of acutely ill patients inspired me to start working in hospital medicine. Evolution of this interest into care-delivery design inspired me to remain in hospital medicine. Joining SHM enabled me to make contacts nationally with people who share similar interests and engage in collaboration, which has been helpful for my growth as a physician.

Q: How has SHM provided you with resources to improve patient care during your time as a member?

A: The SHM annual meetings have provided a consistent framework for dissemination of clinically relevant innovations and discoveries. Each year I’ve attended, I’ve always learned something new from both the posters on display and from a quality improvement presentation. Last year at Hospital Medicine 2016, the HEADS-UP plenary abstract presentation was one very good example of a different approach to interdisciplinary rounding that I would not have been aware of without attending the SHM annual meeting.

Q: How did attending Leadership Academy help you grow to reach your medical director position at Northwestern Memorial?

A: Leadership Academy helped to open my mind to principles of negotiation and expectation management as well as self-awareness, which are not usually presented in medical school or residency. Many of the skills taught can be learned the hard way through the trials of life, but the Leadership Academy accelerated my real-world learning.

My hospital’s leadership recognized the skills I developed with the assistance of Leadership Academy, which helped me to maintain my effectiveness in my medical director role.

Skills obtained in the Leadership Academy helped me to incorporate ward-based afternoon throughput meetings into a hospital-wide patient-flow management network. I also learned to successfully negotiate procurement of chairs for our physicians to sit at the patient’s bedside in the hopes of improving patient satisfaction.

Q: How has your work on the Practice Analysis Committee impacted how you manage your hospital medicine teams?

A: My involvement in the Practice Analysis Committee is yet another example of an opportunity provided by SHM to develop a skills set I would not otherwise have the opportunity to develop. Working on the State of Hospital Medicine survey involves prioritizing information with the burden of the respondents’ time and effort in mind. Sensitivities to stakeholder interest play a major role as well.

Achieving balance between aspiring definitions of concepts to help drive the field and working definitions used heterogeneously throughout the country represents the hardest task of the committee members to sort; I’m very privileged to take the lessons learned through member dialogue and help colleagues apply the lessons locally.

Q: Hospital medicine is celebrating its 20th anniversary this year. How do you see the role of hospitalists evolving over the next 20 years?

A: Change has been a constant in hospital medicine since I began in 2004 and will continue to remain so. Because of the financial and documentary pressures placed on hospitals and physicians, hospital medicine finds itself in a state of flux at the moment. I believe these pressures will drive the 7-on/7-off hospitalist direct-care model as it exists today to evolve into something else. In particular, hospitalist groups, which engage solely in documentation and “decision in name” only and devolve all clinical decision making to another set of physicians in the hospital, are especially nonviable over the long term. I think many hospital administrators believe this as well. Hospital medicine must show value, including in the realm of direct clinical care.

One possibility is that we evolve into a “supervisor” model, where a program is composed of a few experienced hospitalists supervising numerous physician extenders, who in turn rely on multidisciplinary teams in the hospital for clinical decision-making input. Hospitalist physicians will slightly move away from direct clinical decision making in such a model.

Another possibility involves evolution of information support systems to a point where teams of providers organized around a single medical problem, e.g., congestive heart failure, can be replaced, leaving the hospitalist to make patient-centered clinical decisions with updated multidisciplinary input available electronically.

With information systems that provide equal access to evidence-driven guidance for optimal clinical practice, hospitalists will outperform subspecialists at the bedside on patient-centeredness, cost, and availability.

Regardless of how inpatient care evolves, hospital medicine will undoubtedly be at the epicenter of change for years to come. TH

This month, The Hospitalist spotlights G. Randy Smith Jr., MD, MS, SFHM, assistant professor in the Division of Hospital Medicine at the Northwestern University Feinberg School of Medicine and medical director of Unit 16 West at Northwestern Memorial Hospital in Chicago. Dr. Smith is an active member of SHM’s Practice Analysis Committee and a Leadership Academy veteran who has translated his learnings into more efficient rounding and patient-flow methodology.

Question: What inspired you to begin working in hospital medicine and later join SHM?

Answer: Interest in taking care of acutely ill patients inspired me to start working in hospital medicine. Evolution of this interest into care-delivery design inspired me to remain in hospital medicine. Joining SHM enabled me to make contacts nationally with people who share similar interests and engage in collaboration, which has been helpful for my growth as a physician.

Q: How has SHM provided you with resources to improve patient care during your time as a member?

A: The SHM annual meetings have provided a consistent framework for dissemination of clinically relevant innovations and discoveries. Each year I’ve attended, I’ve always learned something new from both the posters on display and from a quality improvement presentation. Last year at Hospital Medicine 2016, the HEADS-UP plenary abstract presentation was one very good example of a different approach to interdisciplinary rounding that I would not have been aware of without attending the SHM annual meeting.

Q: How did attending Leadership Academy help you grow to reach your medical director position at Northwestern Memorial?

A: Leadership Academy helped to open my mind to principles of negotiation and expectation management as well as self-awareness, which are not usually presented in medical school or residency. Many of the skills taught can be learned the hard way through the trials of life, but the Leadership Academy accelerated my real-world learning.

My hospital’s leadership recognized the skills I developed with the assistance of Leadership Academy, which helped me to maintain my effectiveness in my medical director role.

Skills obtained in the Leadership Academy helped me to incorporate ward-based afternoon throughput meetings into a hospital-wide patient-flow management network. I also learned to successfully negotiate procurement of chairs for our physicians to sit at the patient’s bedside in the hopes of improving patient satisfaction.

Q: How has your work on the Practice Analysis Committee impacted how you manage your hospital medicine teams?

A: My involvement in the Practice Analysis Committee is yet another example of an opportunity provided by SHM to develop a skills set I would not otherwise have the opportunity to develop. Working on the State of Hospital Medicine survey involves prioritizing information with the burden of the respondents’ time and effort in mind. Sensitivities to stakeholder interest play a major role as well.

Achieving balance between aspiring definitions of concepts to help drive the field and working definitions used heterogeneously throughout the country represents the hardest task of the committee members to sort; I’m very privileged to take the lessons learned through member dialogue and help colleagues apply the lessons locally.

Q: Hospital medicine is celebrating its 20th anniversary this year. How do you see the role of hospitalists evolving over the next 20 years?

A: Change has been a constant in hospital medicine since I began in 2004 and will continue to remain so. Because of the financial and documentary pressures placed on hospitals and physicians, hospital medicine finds itself in a state of flux at the moment. I believe these pressures will drive the 7-on/7-off hospitalist direct-care model as it exists today to evolve into something else. In particular, hospitalist groups, which engage solely in documentation and “decision in name” only and devolve all clinical decision making to another set of physicians in the hospital, are especially nonviable over the long term. I think many hospital administrators believe this as well. Hospital medicine must show value, including in the realm of direct clinical care.

One possibility is that we evolve into a “supervisor” model, where a program is composed of a few experienced hospitalists supervising numerous physician extenders, who in turn rely on multidisciplinary teams in the hospital for clinical decision-making input. Hospitalist physicians will slightly move away from direct clinical decision making in such a model.

Another possibility involves evolution of information support systems to a point where teams of providers organized around a single medical problem, e.g., congestive heart failure, can be replaced, leaving the hospitalist to make patient-centered clinical decisions with updated multidisciplinary input available electronically.

With information systems that provide equal access to evidence-driven guidance for optimal clinical practice, hospitalists will outperform subspecialists at the bedside on patient-centeredness, cost, and availability.

Regardless of how inpatient care evolves, hospital medicine will undoubtedly be at the epicenter of change for years to come. TH

This month, The Hospitalist spotlights G. Randy Smith Jr., MD, MS, SFHM, assistant professor in the Division of Hospital Medicine at the Northwestern University Feinberg School of Medicine and medical director of Unit 16 West at Northwestern Memorial Hospital in Chicago. Dr. Smith is an active member of SHM’s Practice Analysis Committee and a Leadership Academy veteran who has translated his learnings into more efficient rounding and patient-flow methodology.

Question: What inspired you to begin working in hospital medicine and later join SHM?

Answer: Interest in taking care of acutely ill patients inspired me to start working in hospital medicine. Evolution of this interest into care-delivery design inspired me to remain in hospital medicine. Joining SHM enabled me to make contacts nationally with people who share similar interests and engage in collaboration, which has been helpful for my growth as a physician.

Q: How has SHM provided you with resources to improve patient care during your time as a member?

A: The SHM annual meetings have provided a consistent framework for dissemination of clinically relevant innovations and discoveries. Each year I’ve attended, I’ve always learned something new from both the posters on display and from a quality improvement presentation. Last year at Hospital Medicine 2016, the HEADS-UP plenary abstract presentation was one very good example of a different approach to interdisciplinary rounding that I would not have been aware of without attending the SHM annual meeting.

Q: How did attending Leadership Academy help you grow to reach your medical director position at Northwestern Memorial?

A: Leadership Academy helped to open my mind to principles of negotiation and expectation management as well as self-awareness, which are not usually presented in medical school or residency. Many of the skills taught can be learned the hard way through the trials of life, but the Leadership Academy accelerated my real-world learning.

My hospital’s leadership recognized the skills I developed with the assistance of Leadership Academy, which helped me to maintain my effectiveness in my medical director role.

Skills obtained in the Leadership Academy helped me to incorporate ward-based afternoon throughput meetings into a hospital-wide patient-flow management network. I also learned to successfully negotiate procurement of chairs for our physicians to sit at the patient’s bedside in the hopes of improving patient satisfaction.

Q: How has your work on the Practice Analysis Committee impacted how you manage your hospital medicine teams?

A: My involvement in the Practice Analysis Committee is yet another example of an opportunity provided by SHM to develop a skills set I would not otherwise have the opportunity to develop. Working on the State of Hospital Medicine survey involves prioritizing information with the burden of the respondents’ time and effort in mind. Sensitivities to stakeholder interest play a major role as well.

Achieving balance between aspiring definitions of concepts to help drive the field and working definitions used heterogeneously throughout the country represents the hardest task of the committee members to sort; I’m very privileged to take the lessons learned through member dialogue and help colleagues apply the lessons locally.

Q: Hospital medicine is celebrating its 20th anniversary this year. How do you see the role of hospitalists evolving over the next 20 years?

A: Change has been a constant in hospital medicine since I began in 2004 and will continue to remain so. Because of the financial and documentary pressures placed on hospitals and physicians, hospital medicine finds itself in a state of flux at the moment. I believe these pressures will drive the 7-on/7-off hospitalist direct-care model as it exists today to evolve into something else. In particular, hospitalist groups, which engage solely in documentation and “decision in name” only and devolve all clinical decision making to another set of physicians in the hospital, are especially nonviable over the long term. I think many hospital administrators believe this as well. Hospital medicine must show value, including in the realm of direct clinical care.

One possibility is that we evolve into a “supervisor” model, where a program is composed of a few experienced hospitalists supervising numerous physician extenders, who in turn rely on multidisciplinary teams in the hospital for clinical decision-making input. Hospitalist physicians will slightly move away from direct clinical decision making in such a model.

Another possibility involves evolution of information support systems to a point where teams of providers organized around a single medical problem, e.g., congestive heart failure, can be replaced, leaving the hospitalist to make patient-centered clinical decisions with updated multidisciplinary input available electronically.

With information systems that provide equal access to evidence-driven guidance for optimal clinical practice, hospitalists will outperform subspecialists at the bedside on patient-centeredness, cost, and availability.

Regardless of how inpatient care evolves, hospital medicine will undoubtedly be at the epicenter of change for years to come. TH

Clinical Question: Which oral anticoagulants are safest and most effective in nonvalvular atrial fibrillation?

Background: Use of direct oral anticoagulants (DOACs) has been increasing since their introduction and widespread marketing. While dosing is a challenge for warfarin, certain medical conditions limit the use of DOACs. Choosing the optimal oral anticoagulant is challenging with the increasing complexity of patients.

Study Design: Nationwide observational cohort study.

Setting: Three national Danish databases, from August 2011 to October 2015.

Synopsis: Authors reviewed data from 61,678 patients with nonvalvular atrial fibrillation who were new to oral anticoagulants. The study compared the efficacy, safety, and patient characteristics of DOACs and warfarin. Ischemic stroke, systemic embolism, and death were evaluated separately and as a composite measure of efficacy. Any bleeding, intracranial bleeding, and major bleeding were measured as safety outcomes. DOACs patients were younger and had lower CHA2DS2-VASc and HAS-BLED scores. No significant difference in risk of ischemic stroke was identified between DOACs and warfarin. Rivaroxaban was associated with lower rates of ischemic stroke and systemic embolism but had bleeding rates that were similar to warfarin. Any bleeding and major bleeding rates were lowest for dabigatran and apixaban. All-cause mortality was lowest in the dabigatran group and highest in the warfarin group.

Limitations were the retrospective, observational study design, with an average follow-up of only 1.9 years.

Bottom Line: All DOACs appear to be safer and more effective alternatives to warfarin. Oral anticoagulant selection needs to be based on individual patient clinical profile.

Citation: Larsen TB, Skjoth F, Nielsen PB, Kjaeldgaard JN, Lip GY. Comparative effectiveness and safety of non-vitamin K antagonist oral anticoagulants and warfarin in patients with atrial fibrillation: propensity weighted nationwide cohort study. BMJ. 2016;353:i3189.

Short Take

Mortality and Long-Acting Opiates

This retrospective cohort study raises questions about the safety of long-acting opioids for chronic noncancer pain. When compared with anticonvulsants or antidepressants, the adjusted hazard ratio was 1.64 for total mortality.

Citation: Ray W, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016;315(22):2415-2423.

Clinical Question: Which oral anticoagulants are safest and most effective in nonvalvular atrial fibrillation?

Background: Use of direct oral anticoagulants (DOACs) has been increasing since their introduction and widespread marketing. While dosing is a challenge for warfarin, certain medical conditions limit the use of DOACs. Choosing the optimal oral anticoagulant is challenging with the increasing complexity of patients.

Study Design: Nationwide observational cohort study.

Setting: Three national Danish databases, from August 2011 to October 2015.

Synopsis: Authors reviewed data from 61,678 patients with nonvalvular atrial fibrillation who were new to oral anticoagulants. The study compared the efficacy, safety, and patient characteristics of DOACs and warfarin. Ischemic stroke, systemic embolism, and death were evaluated separately and as a composite measure of efficacy. Any bleeding, intracranial bleeding, and major bleeding were measured as safety outcomes. DOACs patients were younger and had lower CHA2DS2-VASc and HAS-BLED scores. No significant difference in risk of ischemic stroke was identified between DOACs and warfarin. Rivaroxaban was associated with lower rates of ischemic stroke and systemic embolism but had bleeding rates that were similar to warfarin. Any bleeding and major bleeding rates were lowest for dabigatran and apixaban. All-cause mortality was lowest in the dabigatran group and highest in the warfarin group.

Limitations were the retrospective, observational study design, with an average follow-up of only 1.9 years.

Bottom Line: All DOACs appear to be safer and more effective alternatives to warfarin. Oral anticoagulant selection needs to be based on individual patient clinical profile.

Citation: Larsen TB, Skjoth F, Nielsen PB, Kjaeldgaard JN, Lip GY. Comparative effectiveness and safety of non-vitamin K antagonist oral anticoagulants and warfarin in patients with atrial fibrillation: propensity weighted nationwide cohort study. BMJ. 2016;353:i3189.

Short Take

Mortality and Long-Acting Opiates

This retrospective cohort study raises questions about the safety of long-acting opioids for chronic noncancer pain. When compared with anticonvulsants or antidepressants, the adjusted hazard ratio was 1.64 for total mortality.

Citation: Ray W, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016;315(22):2415-2423.

Clinical Question: Which oral anticoagulants are safest and most effective in nonvalvular atrial fibrillation?

Background: Use of direct oral anticoagulants (DOACs) has been increasing since their introduction and widespread marketing. While dosing is a challenge for warfarin, certain medical conditions limit the use of DOACs. Choosing the optimal oral anticoagulant is challenging with the increasing complexity of patients.

Study Design: Nationwide observational cohort study.

Setting: Three national Danish databases, from August 2011 to October 2015.

Synopsis: Authors reviewed data from 61,678 patients with nonvalvular atrial fibrillation who were new to oral anticoagulants. The study compared the efficacy, safety, and patient characteristics of DOACs and warfarin. Ischemic stroke, systemic embolism, and death were evaluated separately and as a composite measure of efficacy. Any bleeding, intracranial bleeding, and major bleeding were measured as safety outcomes. DOACs patients were younger and had lower CHA2DS2-VASc and HAS-BLED scores. No significant difference in risk of ischemic stroke was identified between DOACs and warfarin. Rivaroxaban was associated with lower rates of ischemic stroke and systemic embolism but had bleeding rates that were similar to warfarin. Any bleeding and major bleeding rates were lowest for dabigatran and apixaban. All-cause mortality was lowest in the dabigatran group and highest in the warfarin group.

Limitations were the retrospective, observational study design, with an average follow-up of only 1.9 years.

Bottom Line: All DOACs appear to be safer and more effective alternatives to warfarin. Oral anticoagulant selection needs to be based on individual patient clinical profile.

Citation: Larsen TB, Skjoth F, Nielsen PB, Kjaeldgaard JN, Lip GY. Comparative effectiveness and safety of non-vitamin K antagonist oral anticoagulants and warfarin in patients with atrial fibrillation: propensity weighted nationwide cohort study. BMJ. 2016;353:i3189.

Short Take

Mortality and Long-Acting Opiates

This retrospective cohort study raises questions about the safety of long-acting opioids for chronic noncancer pain. When compared with anticonvulsants or antidepressants, the adjusted hazard ratio was 1.64 for total mortality.

Citation: Ray W, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016;315(22):2415-2423.

Background: Unintentional opioid overdose is a major public health issue. Studies have shown that provision of naloxone to at-risk patients reduces mortality and improves survival. The CDC recommends considering naloxone prescription in high-risk patients. This study focused on patient education and prescription habits of providers rather than just making naloxone available.

Study Design: Non-randomized interventional study.

Setting: Six safety-net primary-care clinics in San Francisco.

Synopsis: The authors identified 1,985 adults on long-term opioid treatment, of which 759 were prescribed naloxone. Providers were encouraged to prescribe naloxone along with opioids. Patients were educated about use of the intranasal naloxone device. Outcomes included opioid-related emergency department visits and prescribed dosage. They noted that patients on a higher dose of opioids and with opioid-related ED visits in the prior 12 months were more likely to be prescribed naloxone. When compared to patients who were not prescribed naloxone, patients who received naloxone had 47% fewer ED visits per month in the first six months and 63% fewer ED visits over 12 months. Limitations include lack of randomization and being a single-center study.

Hospitalists can prioritize patients and consider providing naloxone prescription to reduce ED visits and perhaps readmissions. Further studies are needed focusing on patients who get discharged from the hospital.

Bottom Line: Naloxone prescription in patients on long-term opioid treatment may prevent opioid-related ED visits.

Citation: Coffin PO, Behar E, Rowe C, et al. Nonrandomized intervention study of naloxone coprescription for primary care patients receiving long-term opioid therapy for pain. Ann Intern Med. 2016;165(4):245-252.

Short Take

Mortality and Long-Acting Opiates

This retrospective cohort study raises questions about the safety of long-acting opioids for chronic noncancer pain. When compared with anticonvulsants or antidepressants, the adjusted hazard ratio was 1.64 for total mortality.

Citation: Ray W, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016;315(22):2415-2423.

Background: Unintentional opioid overdose is a major public health issue. Studies have shown that provision of naloxone to at-risk patients reduces mortality and improves survival. The CDC recommends considering naloxone prescription in high-risk patients. This study focused on patient education and prescription habits of providers rather than just making naloxone available.

Study Design: Non-randomized interventional study.

Setting: Six safety-net primary-care clinics in San Francisco.

Synopsis: The authors identified 1,985 adults on long-term opioid treatment, of which 759 were prescribed naloxone. Providers were encouraged to prescribe naloxone along with opioids. Patients were educated about use of the intranasal naloxone device. Outcomes included opioid-related emergency department visits and prescribed dosage. They noted that patients on a higher dose of opioids and with opioid-related ED visits in the prior 12 months were more likely to be prescribed naloxone. When compared to patients who were not prescribed naloxone, patients who received naloxone had 47% fewer ED visits per month in the first six months and 63% fewer ED visits over 12 months. Limitations include lack of randomization and being a single-center study.

Hospitalists can prioritize patients and consider providing naloxone prescription to reduce ED visits and perhaps readmissions. Further studies are needed focusing on patients who get discharged from the hospital.

Bottom Line: Naloxone prescription in patients on long-term opioid treatment may prevent opioid-related ED visits.

Citation: Coffin PO, Behar E, Rowe C, et al. Nonrandomized intervention study of naloxone coprescription for primary care patients receiving long-term opioid therapy for pain. Ann Intern Med. 2016;165(4):245-252.

Short Take

Mortality and Long-Acting Opiates

This retrospective cohort study raises questions about the safety of long-acting opioids for chronic noncancer pain. When compared with anticonvulsants or antidepressants, the adjusted hazard ratio was 1.64 for total mortality.

Citation: Ray W, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016;315(22):2415-2423.

Background: Unintentional opioid overdose is a major public health issue. Studies have shown that provision of naloxone to at-risk patients reduces mortality and improves survival. The CDC recommends considering naloxone prescription in high-risk patients. This study focused on patient education and prescription habits of providers rather than just making naloxone available.

Study Design: Non-randomized interventional study.

Setting: Six safety-net primary-care clinics in San Francisco.

Synopsis: The authors identified 1,985 adults on long-term opioid treatment, of which 759 were prescribed naloxone. Providers were encouraged to prescribe naloxone along with opioids. Patients were educated about use of the intranasal naloxone device. Outcomes included opioid-related emergency department visits and prescribed dosage. They noted that patients on a higher dose of opioids and with opioid-related ED visits in the prior 12 months were more likely to be prescribed naloxone. When compared to patients who were not prescribed naloxone, patients who received naloxone had 47% fewer ED visits per month in the first six months and 63% fewer ED visits over 12 months. Limitations include lack of randomization and being a single-center study.

Hospitalists can prioritize patients and consider providing naloxone prescription to reduce ED visits and perhaps readmissions. Further studies are needed focusing on patients who get discharged from the hospital.

Bottom Line: Naloxone prescription in patients on long-term opioid treatment may prevent opioid-related ED visits.

Citation: Coffin PO, Behar E, Rowe C, et al. Nonrandomized intervention study of naloxone coprescription for primary care patients receiving long-term opioid therapy for pain. Ann Intern Med. 2016;165(4):245-252.

Short Take

Mortality and Long-Acting Opiates

This retrospective cohort study raises questions about the safety of long-acting opioids for chronic noncancer pain. When compared with anticonvulsants or antidepressants, the adjusted hazard ratio was 1.64 for total mortality.

Citation: Ray W, Chung CP, Murray KT, Hall K, Stein CM. Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA. 2016;315(22):2415-2423.